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

2. 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

3. 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 – 15000 women will present each year

4. 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

5. 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)

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

7. 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

8. 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

9. 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.

10. 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

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

12. References Clinical practice guidance for the assessment of young women aged 20-24 with abnormal vaginal bleeding. DoH Mar2010. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalasse ts/@dh/@en/@ps/documents/digitalasset/dh_113553.pdf http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalasse ts/@dh/@en/@ps/documents/digitalasset/dh_113553.pdf Management of unscheduled bleeding in women using hormonal contraception. FSRH May2009. http://www.rcog.org.uk/files/rcog- corp/UnscheduledBleeding23092009.pdf http://www.rcog.org.uk/files/rcog- corp/UnscheduledBleeding23092009.pdf Persistant PCB. RCOG Query bank. http://www.rcog.org.uk/womens-health/clinical- guidance/persistent-post-coital-bleeding-query-bank http://www.rcog.org.uk/womens-health/clinical- guidance/persistent-post-coital-bleeding-query-bank