How to manage menstrual disorders in general practice and when to refer to secondary care

Dr Kristina NaidooConsultant Gynaecologist

Menstrual DisordersDefining normalityDefining problemInvestigations Treatment

Normal menstruationMost menstrual cycles 22 to

35 daysNormal menstrual flow 3 to 7

days Most blood loss occurs

within first 3 daysMenstrual flow amounts to

35ml*In general, most normal

menstruating women use five or six pads or tampons per day.

Menarche/MenopauseMenarche average age 12.9

Anovulatory cycles 80% in first year, 10% in 6th year

Menopause 42-58 (average 51)

Postmenopausal bleeding > 1 year after the last menses

Symptoms of AUBHeavy menstrual bleedingIntermenstrual bleeding (IMB)Postcoital bleeding (PCB)Irregular menstrual cyclePostmenopausal bleeding

+/-pain

FIGO classification of Causes of AUB (non-pregnancy)

PALM-COEINP polypsA adenomyosisL leiomyomaM malignancy & hyperplasiaC coagulopathyO ovulatory disordersE endometrial causesI iatrogenicN not classified

When to referSuspected cancer- symptoms

PCB lasting more than 4 weeks over 35 yearsIMB persistent and unexplained 1 or more episodes of PMB and NOT on HRTPersistent or unexplained PMB 6/52 after

cessation of HRTAny unscheduled bleeding on Tamoxifen

NOT Repeated, unexplained PCB

When to refer Suspected cancer- signs

Palpable abdominal/pelvic mass not obviously fibroids/urinary or GI

Lesion on cervix suspicious of cancer

Unexplained vulval lump

Vulval bleeding due to ulceration

Heavy Menstrual Bleeding(HMB)

Excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life

It can occur alone or in combination with other symptoms

HMBBlood loss is subjective30% women consider their bleeding to be

excessiveHalf of these have a normal blood loss

(<80ml)Women aged 30-49, 1:20 consults GP re

HMB each yearHMB accounts for 12% of Gynae referrals£7 million a year spent on prescriptions in

primary care (2007)

Mirena LNG-IUSProvided long-term use (at least 12 months

anticipated)Prevents endometrial proliferation.Contraceptive.Doesn't impact future fertility.Unwanted outcomes: irregular bleeding that can last

for six months; amenorrhoea; progestogen-related problems such as breast tenderness, acne and headaches; uterine perforation at insertion (1 in 100,000 chance).

As equally effective in improving quality of life and psychological well-being as hysterectomy.

Submucous fibroid and Mirena IUS

Tranexamic acidOral antifibrinolytic .If no improvement, stop after three cycles.Unwanted outcomes: indigestion; diarrhoea;

headache.No increased risk of thrombosis. Cochrane

review.Dose: 500 mg tablets. 2 to 3 tablets (1-1.5g

three to four times daily for three to four days. From onset of heavy bleeding.

NSAIDsCommonly used: mefenamic acidReduce production of prostaglandin.If no improvement, stop after three cycles.Preferred over tranexamic acid in

dysmenorrhoea.Unwanted outcomes: indigestion; diarrhoea;

worsening of asthmaDose: mefenamic acid 500 mg tablets. 1

tablet three times daily during heavy bleeding.

COCPs

Prevent proliferation of the endometrium.Also act as a contraceptive.Do not impact future fertility.Unwanted outcomes: mood change;

headache; nausea; fluid retention; breast tenderness; DVT; MI; CVA.

Oral progestogenCommonly used: NorethisteronePrevents proliferation of the endometrium.Does not impact future fertility.Dose: 15 mg daily on days 5-26 of the cycle.Unwanted outcomes: weight gain; bloating;

breast tenderness; headaches; acne; depression.A recent Cochrane Review showed that this

regime of progestogen results in a significant reduction in menstrual blood loss but that women find the treatment less acceptable than intrauterine levonorgestrel.

Injected progestogenDepot-medroxyprogesterone acetatePrevents proliferation of the endometrium.Contraceptive.Does not impact on future fertility.Unwanted outcomes: as for oral progs; weight gain;

irregular bleeding; amenorrhoea; bone density loss.Current guidance:Use in adolescents as last resort. Other women re-evaluate after 2 years, if significant

risk factors for osteoporosis consider alternative.

When to referSuspicion from history of increased risk of

pathology:

E.g. family history of endometrial or colonic cancer

Infertility/nulliparityObesity/diabetes Unopposed oestrogen therapyPCOS

‘One stop’ Menstrual Dysfunction ClinicConventional pathway ‘One stop’ pathway

General Gynaecology Clinic ?biopsy

‘One stop’ menstrual dysfunction clinic

Pelvic scan

Review, list for Day Case Hysteroscopy

Pre-operative assessment clinic

Hysteroscopy under GA

Follow-up to plan management

Outpatient HysteroscopyRCOG

recommendation2012 favourable

tariff Diagnosis of benign

intrauterine pathology

TreatmentResection polyps,

small fibroids, RPOCs

IUD retrieval

ConclusionsReassurance re normal patterns of bleedingFull blood count -first line investigationLow threshold for pelvic scanning (TVS) Hormonal contraception for HMB

Red flag symptoms-> HSC205 pathwayRisk factors for endometrial pathology->

refer early‘One stop’ clinics advantageous