Max Brinsmead MB BS PhDMay 2015

The common causes are… Pregnancy-related

○ Miscarriage – threatened, inevitable or incomplete○ Ectopic

Cervical BleedingBenign

Ectropion, Cervicitis or PolypCancer of the cervix

Rare in patients who have regular Pap smears)

Bleeding from the uterine cavityBenign

Fibroids and PolypsCancer

Dysfunctional uterine bleedingA diagnosis made after excluding other causes

But also keep in mind… Hormones that have been given

○ Depoprovera (or DMP or DMPA)○ Oral contraceptives (COC)○ Other (some OTC drugs affect cycles)

Bleeding disorders○ Rare○ Usually associated with other bleeding or

bruising

When a patient complains about abnormal vaginal bleeding... First determine if she has:

○ Regular but heavy or prolonged periodsThis is called menorrhagiaIt is a common manifestation of fibroidsRarely due to a bleeding disorder

○ Regular periods with bleeding at other timesIf the bleeding is postcoital it should be regarded as

cancer of the cervix until proven otherwise

○ Irregular bleedingThis may be dysfunctional uterine bleeding but this

diagnosis is can only made when other causes are excluded

And always exclude pregnancyBest done by pregnancy test

Consider your patient’s age… If the patient is young (<40 years)

○ Endometrial cancer is uncommon○ But Ca cervix always needs to be ruled out

If the patient is very young & never sexually active

○ Pregnancy, STD and Ca cervix never occurs○ But dysfunctional uterine bleeding is not

uncommon

If the patient is >45 years○ Cancer from within the uterine cavity can only

be excluded by endometrial biopsy or curette○ Check also for Ca cervix○ But dysfunctional bleeding is not uncommon

You must always examine…

Look for signs of anaemia Examine the abdomen to see if there is a

uterus or other mass arising out of the pelvis

Pass a speculum and decide if the bleeding is coming from or through the cervix

Look carefully at the cervix Examine the pelvis bimanually to see if the

uterus is enlarged○ (And if the cervix feels normal even if it looked

abnormal)

Tests you should perform

FBC to check HB & platelet count Pap smear if not recently performed

But this is not a test for cervical cancer!

Cervical or 1st voided urine for Chlamydia if the patient is at risk of STD

Ultrasound of the uterus has a limited roleBut should be performed if the uterus is

enlargedIt is NOT a substitute for clinical examination

Dysfunctional Uterine Bleeding (DUB) There is often a history of missed periods

or irregular cycles May be associated with obesity and

hirsutism (PCO Disorder) Bleeding is usually painless

Unless there is clot colic

Bleeding can be very heavy or quite prolonged

There is a normal cervix and the uterus is not enlarged

Management of Abnormal Vaginal Bleeding Antibiotics are indicated only for proven STI Bleeding from an abnormal cervix is rarely a

life-threatening emergencyBut it generally requires referral for further testing

and treatment

Transfusion should be reserved for those with severe anaemia and in whom you cannot immediately control the bleeding

Uterine bleeding after the age of 45 requires referral for D&C or biopsy

Dysfunctional uterine bleeding can be treated with oral hormone therapy (Progestin or COC)

Management of Dysfunctional Uterine Bleeding Bleeding can be controlled with Norethisterone Give 2x 5m tablets every 2 – 3 hours until

the bleeding slows or stops Then 5 mg BD for 10 – 14 days The patient can then expect a “normal

period” a few days after stopping the pills Give COC in the next cycle or Norethisterone 5 mg BD from day 10 –

25 of each cycle for 4 – 6 months Give oral iron ± folate to treat anaemia

Emergency treatment of any Endometrial Bleeding

When the blood is coming through the cervix

Even if the patient is >45 years Or if the uterus is enlarged by

adenomyosis or fibroids Or the patient has a bleeding disorder You can try Norethisterone 10 mg every 2

– 3 hours But refer also for further Ix and Rx

Management of Hormone-related PV bleeding

Irregular PV bleeding with Depoprovera or COC is secondary to their effect on the endometrium

But make sure that the cervix is normal Then try Norethisterone as per DUB

regimenOr give Premarin 1.25 mg 8 hourlyOr any COC one tablet 6 hourlyOr just give another injection of Depot ProveraAn episode of bleeding can be shortened with

Mefanamic acid 500 mg BD for 5 days

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