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