1. Dr Kristina Naidoo Consultant Gynaecologist
How to manage menstrual disorders in general practice and when to refer to secondary care
Dr Kristina Naidoo
Consultant Gynaecologist

2. Menstrual Disorders Defining normality Defining problem Investigations
Treatment

3. Normal menstruation Most menstrual cycles 22 to 35 days
Normal menstrual flow 3 to 7 days
Most blood loss occurs within first 3 days
Menstrual flow amounts to 35ml*
In general, most normal menstruating women use five or six pads or tampons per day.

4. Menarche/Menopause Menarche average age 12.9
Anovulatory cycles 80% in first year, 10% in 6th year
Menopause (average 51)
Postmenopausal bleeding > 1 year after the last menses

5. Symptoms of AUB Heavy menstrual bleeding Intermenstrual bleeding (IMB)
Postcoital bleeding (PCB)
Irregular menstrual cycle
Postmenopausal bleeding
+/-pain
Intermenstrual bleeding refers to vaginal bleeding (other than postcoital) at any time during the menstrual cycle other than during normal menstruation. It can sometimes be difficult to differentiate true intermenstrual bleeding from metrorrhagia (irregularly frequent periods). Postcoital bleeding is non-menstrual bleeding that occurs immediately after sexual intercourse.
Both are symptoms, rather than diagnoses, and warrant further assessment. They occur commonly and are emphasised in referral guidelines for suspected gynaecological cancers. Whilst genital tract malignancy is an uncommon cause of bleeding and a rare cause in young women, it must be considered in all patients.
Epidemiology
Self-reported intermenstrual bleeding (IMB) and postcoital bleeding (PCB) have an annual cumulative incidence of 17% and 6% respectively in menstruating women from a questionnaire study based on subjects within an urban English, general practice setting.[1]
PCB occurs in % of women with cervical cancer. The risk of a woman seen in the community with PCB having cervical cancer is approximately 1 in 44,000 in year olds and 1 in 2,400 in year olds.[2]
In another English study, looking at pathological findings from a group of women referred to colposcopy for PCB but with a negative previous cervical smear, a third had an ectropion, 12% had cervical polyps, 7% had cervical intraepithelial neoplasia (CIN), 2% had chlamydia but nobody in this study had invasive cancer.[3]
Only 2% of endometrial cancers occur before 40 years old. Risk factors for endometrial cancer include: nulliparity, diabetes, obesity, polycystic ovary syndrome, unopposed oestrogen therapy, chronic anovulatory cycles and the use of tamoxifen. Women with risk factors and IMB should be fully investigated.

6. FIGO classification of Causes of AUB (non-pregnancy) PALM-COEIN
P polyps
A adenomyosis
L leiomyoma
M malignancy & hyperplasia
C coagulopathy
O ovulatory disorders
E endometrial causes
I iatrogenic
N not classified

7. When to refer Suspected cancer- symptoms
PCB lasting more than 4 weeks over 35 years
IMB persistent and unexplained
1 or more episodes of PMB and NOT on HRT
Persistent or unexplained PMB 6/52 after cessation of HRT
Any unscheduled bleeding on Tamoxifen
NOT Repeated, unexplained PCB

8. 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

9. 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

10. HMB Blood loss is subjective
30% women consider their bleeding to be excessive
Half of these have a normal blood loss (<80ml)
Women aged 30-49, 1:20 consults GP re HMB each year
HMB accounts for 12% of Gynae referrals
£7 million a year spent on prescriptions in primary care (2007)
Dysfunctional uterine bleeding (DUB) is more common around the menarche and perimenopause.
The perception of what is heavy menstrual bleeding is subjective and 30% of women consider their bleeding to be excessive.[4]
Only half of women complaining of heavy menstrual bleeding fit the clinical criteria of more than 80 mls blood loss per cycle.[5]
Pictorial blood-loss assessment charts are available.[6]
Among women aged 30-49, one in 20 consults her GP each year with menorrhagia.[2]
Heavy menstrual bleeding accounts for 12% of all gynaecology referrals in the UK.[7]
Each year around £7 million is spent in the UK on prescriptions in primary care to treat menorrhagia.[2]

13. Mirena LNG-IUS Provided 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.
First-line: levonorgestrel-releasing intrauterine system, provided long-term use (at least 12 months) is anticipated.
Prevents endometrial proliferation.
Also acts as a 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.[8][9]

14. Submucous fibroid and Mirena IUS

15. Tranexamic acid Oral 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.
Tranexamic acid
Oral antifibrinolytic.
If no improvement, stop after three cycles.
Can be used in parallel with investigations.
Not a contraceptive.
Unwanted outcomes: indigestion; diarrhoea; headache.
Has been reluctance to prescribe due to potential increased risk of thrombosis.
Studies in Sweden have shown that incidence of thrombosis in women treated with tranexamic acid is comparable with the spontaneous frequency of thrombosis in women. [10] A Cochrane Review showed that there are no data available within randomised controlled trials which record the frequency of thromboembolic events during treatment with tranexamic acid.[11]
Dose: 500 mg tablets. 2 to 3 tablets three to four times daily for three to four days. Therapy is indicated only after heavy bleeding has started.[12]

16. NSAIDs Commonly used: mefenamic acid
Reduce production of prostaglandin.
If no improvement, stop after three cycles.
Preferred over tranexamic acid in dysmenorrhoea.
Unwanted outcomes: indigestion; diarrhoea; worsening of asthma
Dose: mefenamic acid 500 mg tablets. 1 tablet three times daily during heavy bleeding.
Commonly used examples: mefenamic acid.
Oral tablets that reduce production of prostaglandin.
If no improvement, stop after three cycles.
Can be used in parallel with investigations.
Preferred over tranexamic acid in dysmenorrhoea.
Not a contraceptive.
Unwanted outcomes: indigestion; diarrhoea; worsening of asthma in sensitive individuals; peptic ulcer.
Dose: mefenamic acid 500 mg tablets. 1 tablet three times daily during heavy bleeding.

17. 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.
. 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; deep vein thrombosis; myocardial infarction; cerebrovascular event.

18. Oral progestogen Commonly used: Norethisterone
Prevents 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.
5. Oral progestogen (norethisterone)
Prevents proliferation of the endometrium.
Also acts as a contraceptive.
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.[3]

19. Injected progestogen Depot-medroxyprogesterone acetate
Prevents 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.
Injected progestogen (depot-medroxyprogesterone acetate)
Prevents proliferation of the endometrium.
Also acts as a contraceptive.
Does not impact on future fertility.
Unwanted outcomes: weight gain; irregular bleeding; amenorrhoea; bloating; fluid retention; breast tenderness; bone density loss.
Due to the potential for bone density loss, current guidance is that depot-medroxyprogesterone acetate should only be used in adolescents if other treatments for heavy menstrual bleeding are unsuitable, ineffective or unacceptable. In women of all ages, careful re-evaluation of the risks and benefits of use should be carried out at two years. If there are significant risk factors for osteoporosis, alternative treatment for heavy menstrual bleeding should be considered first.[13]

20. When to refer Suspicion from history of increased risk of pathology:
E.g. family history of endometrial or colonic cancer
Infertility/nulliparity
Obesity/diabetes
Unopposed oestrogen therapy
PCOS

25. ‘One stop’ Menstrual Dysfunction Clinic
Conventional 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

26. Outpatient Hysteroscopy
RCOG recommendation
2012 favourable tariff
Diagnosis of benign intrauterine pathology
Treatment
Resection polyps, small fibroids, RPOCs
IUD retrieval

27. Conclusions Reassurance re normal patterns of bleeding
Full blood count -first line investigation
Low threshold for pelvic scanning (TVS)
Hormonal contraception for HMB
Red flag symptoms-> HSC205 pathway
Risk factors for endometrial pathology-> refer early
‘One stop’ clinics advantageous