unscheduled bleeding in young women dr kathryn hill gpst2 in o+g
TRANSCRIPT
Unscheduled bleeding in young women
Dr Kathryn HillGPST2 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 – 15000 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 1st 3mUsually settlesUse lowest oestrogen dose for cycle controlMay need to increase from 20mcg to 30-35mcgNo evidence tricycling settles bleeding
Progesterone onlyBleeding 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% irregularLater – 50% regular bleed and 30-40% irregularNo evidence changing type of pill will helpNo evidence that 2 pills per day will help
Injectable:35% amenorrhoeic at 3m and 70% at 1yNo evidence reducing interval improves bleedingMefenamic 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
bleedingDoxycycline may help but limited evidence
IUS:Irregular, light or heavy in 1st 6m65% have amenorrhoea or reduced bleeding at 1yNo evidence for treatment options
Injectable / Implant / IUS:COC upto 3m (usual use or continuous) recommended if not contraindicated
Summary
HistoryConsider examinationConsider investigation for infectionsModify hormonal contraceptionRefer if persistant bleeding for 6-8 week
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_digitalassets/@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
Persistant PCB. RCOG Query bank. http://www.rcog.org.uk/womens-health/clinical-guidance/persistent-post-coital-bleeding-query-bank