Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G

Aims To review the guidelines on the management of abnormal vaginal bleeding in young women To concentrate on the investigation/ management to be carried out before referral to colposcopy clinic

Why is it important? 1/600 women aged 20-24y reported PCB per year 0.5-1% women aged 20-24y present with IMB/ year Estimated 7500 – women will present each year

DoH Clinical Practice Guidelines Women aged 20-24y Abnormal vaginal bleeding relatively common To prevent delay of referral to colposcopy in rare cases of cancer

Management - PCB History Speculum examination If clinically suspicious 2ww If local problem treat or refer If normal for swabs Refer if bleeding persists 6-8 weeks Women over 35y PCB >4w refer colposcopy (Scottish Guidelines)

Management - IMB History If suspected OCP problem – modify contraception If bleeding persists (6-8 weeks) – speculum

FSRH - management of unscheduled bleeding on hormonal contraception Frequent / prolonged / irregular / spotting Many due to method of hormonal contraception Endometrial and cervical cancer rare Early vs late symptoms May not need examination

FSRH - management of unscheduled bleeding on hormonal contraception COCP/ Patch/ Ring: Upto 20% have irregular bleeding in 1 st 3m Usually settles Use lowest oestrogen dose for cycle control May need to increase from 20mcg to 30-35mcg No evidence tricycling settles bleeding Progesterone only Bleeding pattern on one method does not predict bleeding patterns with another method

FSRH - management of unscheduled bleeding on hormonal contraception POP: Early - 30% change in bleeding and 10% irregular Later – 50% regular bleed and 30-40% irregular No evidence changing type of pill will help No evidence that 2 pills per day will help Injectable: 35% amenorrhoeic at 3m and 70% at 1y No evidence reducing interval improves bleeding Mefenamic acid 500mg bd 5d reduced length of bleeding episode. No long term effect.

FSRH - management of unscheduled bleeding on hormonal contraception Implant: At 6m 30% infrequent and 10-20% prolonged bleeding Doxycycline may help but limited evidence IUS: Irregular, light or heavy in 1 st 6m 65% have amenorrhoea or reduced bleeding at 1y No evidence for treatment options Injectable / Implant / IUS: COC upto 3m (usual use or continuous) recommended if not contraindicated

Summary History Consider examination Consider investigation for infections Modify hormonal contraception Refer if persistant bleeding for 6-8 week

References Clinical practice guidance for the assessment of young women aged with abnormal vaginal bleeding. DoH Mar Management of unscheduled bleeding in women using hormonal contraception. FSRH May corp/UnscheduledBleeding pdf corp/UnscheduledBleeding pdf Persistant PCB. RCOG Query bank. guidance/persistent-post-coital-bleeding-query-bank guidance/persistent-post-coital-bleeding-query-bank