Vaginal Bleeding
Menorrhagia
Preferred term is Heavy Menstrual Bleeding (HMB)
Excessive flow and duration at regular intervals (vs Metrorrhagia = irregular bleeding)
- 1st need to establish pregnant vs non-pregnant
- The goal of the work-up is to determine whether there is a uterine/endometrial abnormality, a disorder of ovulation, or a disorder of coagulation
- The International Federation of Gynaecology and Obstetrics developed a mnemonic for these disorders: PALM-COEIN
- P olyp; A denomyosis; L eiomyoma; M alignancy and hyperplasia
- C oagulopathy
- O vulatory dysfunction
- E ndometrial
- I atrogenic
- N ot yet classified)
History should then be focused on:
| Pelvic pain/pathology | • fibroids, malignancy • Polycystic Ovary Syndrome |
|---|---|
| Contraceptive use | • |
| Endocrine causes | • pituitary tumour - Galactorrhea • adrenal - Hirsutism • Thyroid disease |
| Systemic illnesses | • renal, hepatic |
| Bleeding disorders | • Duration of menses ≥7/7, impairment of daily duties • History of Rx for anaemia • FHx of bleeding disorder • Excessive bleeding with tooth extraction, other surgery etc • Family Hx |
| Medications | • hormones or anticoagulants |
| Any past procedures | • including unsuccessful hormone manipulations |
Examination should focus on:
- signs of volume loss is priority
- signs of bleeding diathesis
- signs of endocrine disorder
- abdominal and pelvic masses
- VE for signs of infection or mass
Acute Management
- Fluid resuscitation
- addressing contributing illnesses and correctable factors - bleeding disorders, anti-coag med's etc
- Investigation - routine bloods, TFT, prolactin (+/- LH, FSH and adrenal test), coag's, Fe then others depending on background. USS
| NSAIDs | • evidence for increased local inflammation with increased menstrual blood loss (increased TNF and COX-2) • Mefenamic acid most commonly used. Said to reduce blood loss by ~25% • Other NSAIDs also useful |
|---|---|
| Tranexamic acid (TXA) | • anti-fibrinolytic with short t1/2 • Said to reduce blood loss by ~50% • 1g tds - qid. |
| Hormones | • progesterone only • although safer than combined pill, not usually recommended because of irregular and unpredictable blood loss • May be appropriate if other options not available |
| • Norethisterone = most common oral progesterone used. • Said to reduce blood loss by ~80%. • 5mg - tds |
|
| • combined pill - oestrogen risk of VTE, CVS disease, stroke and breast CA |
Bleeding in early pregnancy
- <6/40, painless bleeding, consider expectant management
- Advise pt to repeat urine pregnancy test in 7–10/7 and return if test +ve or symptoms continue or worsen
- should be referred if +ve urine pregnancy test, or continuing or worsening symptoms to EPAU
Progesterone levels in pregnancy: Prog levels
- Pregnancy 1st trimester: 11.2 to 90.0 ng/mL or 35.62 to 286.20 nmol/L
- Pregnancy 2nd trimester: 25.6 to 89.4 ng/mL or 81.41 to 284.29 nmol/L
- Pregnancy 3rd trimester: 48 to 150 to 300 or more ng/mL or 152.64 to 477 to 954 or more nmol/L