Gynaecological bleeding
1.
Abnormal uterine bleeding
2.
Postmenopausal bleeding
3.
Prepubertal vaginal bleeding
4.
Contraceptive side effects
Stefan Gebhardt
gsgseb@sun.ac.za
Normal menstrual cycle
Estradiol
Progesterone
LH
14
28
Anovulation
LH
FSH
Estradiol
Progesterone
0
14
28
Gynaecological bleeding
Estrogen withdrawal
Estrogen breakthrough
Progesterone withdrawal
Progesterone breakthrough
Estrogen withdrawal
After oophorectomy
After withdrawal of exogenous
estrogens
Midcycle
Estrogen withdrawal
Estrogen breakthrough
Constant low doses- prolonged, intermittent
spotting
Sustained high levels of estrogen- prolonged
periods of amenorrhoea followed by profuse
bleeding
Estrogen breakthrough
Progesterone withdrawal
Removal of corpus luteum (normal
menstruation)
Discontinuation of progesterone treatment
(eg Riley test)
Only if endometrium proliferated by estrogen
Progesterone breakthrough
Only in the presence of unfavourably
high ratio of progesterone to estrogen
eg long-acting progesterone only
contraception (Depo Provera, Nur Isterate
etc.) or oral contraception
1. Abnormal uterine bleeding
Dysfunctional uterine bleeding
No specific cause found
Failure to control with hormonal therapy
excludes diagnosis
=often anovulatory
Diagnosis
Medical and gynaecological history
Pregnancy test
Gynaecological examination
Management on clinical findings
Women 20-35
Normal weight
No clear risk factors for STI
No signs of excess androgens
Not using any hormones
No abnormal findings
Treatment
Progesterone therapy
Medroxyprogesterone acetate (Provera)
or Norethisterone (Primolut-N) 10 mg
per day for 10-20 days per month
Oral contraception if desired
Treatment
Oral contraception
Low dose combination monophasic
Brevinor
Nordette
Femodene
Minulette
Melodene
Minesse
Mirelle
Marvelon
Mercilon
Treatment
Progesterone therapy
If progesterone does not correct
bleeding, do further diagnostic
procedures
Diagnostic procedures
Pelvic ultrasound
Endometrial sampling
D&C
Clotting profile
Hysteroscopy
Treatment
Estrogen therapy
Prolonged bleeding, progesterone
therapy, thin endometrium (ultrasound)
Conjugated estrogen (Premarin 1.25mg) daily
for 7-10 days, followed by Estrogen +
progesterone (Provera 10 mg daily) for 7 days
Treatment
Estrogen therapy
High doses of estrogen temporarily
stops most dysfunctional bleeding
Conjugated estrogen (Premarin
1.25mg) daily for 7-10 days
Treatment- emergency
Estrogen therapy
Conjugated estrogen (Premarin 1.25mg) 6
hourly for 24 hours, followed by 1.25 mg daily
for 7-10 days, followed by combination E+P
Or 25 mg Premarin IV every four hours until
bleeding stops (+ resuscitation)
Treatment- other modalities
Antifibrinolytic drugs
Tranexamic acid (Cyklokapron)
1g 3-4x/day for 1st four days of cycle
Nonsteroidal anti-inflammatory drugs
1st four days of cycle
Treatment- other modalities
Medicated intra-uterine system (Mirena)
reduce blood loss in menorrhagia
Danazol (side-effects- do not use)
GnRH analogues (eg Zoladex) < 6
months (expensive, side effects)
Treatment- special cases
Patient >35-40 years- always do
diagnostic procedures before starting
therapy
Polyps, miomas, hyperplasia,
endometrial or cervical cancer etc
Treatment- special cases
Adolescents- usually anovulatory
Can be conservative (reassurance,
counseling, menstrual calendar)
Hormone therapy
Treatment- surgical
Endometrial ablation
Hysterectomy
2. Postmenopausal bleeding
Menopause: diagnosis retrospective
Postmenopausal bleeding: any vaginal
bleeding (even bloody discharge) after at
least 6 months amenorrhoea, at the age of
the menopause
Malignant until proven otherwise
Menstruation after 55/ abnormal
menstruation ominous
CAUSES
Atrophic vaginitis (most common)
Hyperplasia
Polyps
Exogenous estrogens (HRT)
Malignancy (endometrial, cervical,
vagina etc)
Other: trauma, bladder, rectum
Management
History
Clinical examination
Cytology smear
Ultrasound
Histology
Postmenopausal
bleeding
Cytology
VCE smear
Ultrasound
Ultrasound: atrophy
Thickness: 4mm or
less (5mm)
Regular
No fluid collections
Ultrasound: histology
Thickness: >4mm
Irregular
Fluid collections
(cone biopsy!)
Histology
Office procedure (Accurette,
Pipelle, etc)
Formal dilation and curettage
(differential, DD&C)
Management
Atrophy
local estrogen cream for one
month
hormone replacement therapy
Management
Malignancy
refer to gynaecologist/ oncologist
Endometrial hyperplasia
Simple hyperplasia
without atypia
with atypia
Risk for Carcinoma
1%
8%
Complex hyperplasia
without atypia
with atypia
3%
29%
Management
Hyperplasia: without atypia
continuous progesterone
treatment (e.g.
medroxyprogesterone acetate 5
mg daily for three months)
followed by repeat histology
if normal then, consider hormone
replacement therapy
Management
Hyperplasia: with atypia
Total abdominal hysterectomy
and bilateral salpingooophorectomy advised
Polyps: remove with D&C
(histology)
3. Prepubertal vaginal bleeding
Precocious puberty (breasts <8 years;
menarche <9 years)
Foreign bodies (offensive discharge)
Vaginitis (atrophic)
Tumours (cervix, vagina, uterus)
Accidental ingestion of hormones (Mother)
Prepubertal vaginal bleeding
Assessment of secondary sexual
characteristics
Proper examination (anaesthesia if
necessary)
Treat cause
Prepubertal vaginal bleeding
Precocious puberty (breasts <8 years; menarche <9 years)
Refer to endocrinologist
Foreign bodies (offensive discharge)
Remove
Vaginitis (atrophic)
-Estrogen cream + antibiotics
Tumours (cervix, vagina, uterus)
Refer to oncologist
Accidental ingestion of hormones (Mother)
-Conservative
4. Abnormal bleeding on
contraceptives
Satellite symposium: Update in Family Planning
23 August 2002
Bellville Park Campus + 23 other venues in South
Africa
Enquiries Judy Geldenhuys tel 938 4504
4. Bleeding on contraceptives
Slight bleeding
exclude pathology (ectopy, polyps)
reassure
bleeding only needs treatment if it
persists or is excessive
4. Bleeding on contraceptives
Bleeding shortly after
commencement of depo MPA
repeat another 150-300 mg
only instance where this approach will
work
based on inadequate endometrial
suppression
4. Bleeding on contraceptives
Bleeding after long-term use of
depo MPA
Usually due to atrophic endometrium
Exclude pathology
Add estrogen 20 microgram po, daily
for three weeks/month x2-3 months
(+ continue Depo)
4. Bleeding on contraceptives
Breakthrough bleeding on oral contraceptives
Exclude pathology
In first half of cycle- usually due to insufficient
estrogen stimulation
Minor bleeding- continue pill and wait
Change to pill with higher estrogen content if
bleeding persists (eg Biphasil)
Regard severe breakthrough bleeding as a
menstruation and start a new packet
4. Bleeding on contraceptives
Breakthrough bleeding on oral
contraceptives
In second half of cycle- usually due to
insufficient progestogen stimulation
Change to pill with higher
progestogen content (eg Nordiol,
Ovral, Norinyl)
Thank you
gsgeb@sun.ac.za
www.sun.ac.za/obs
