In this episode of PodMD, experienced Obstetrician & Gynaecologist Dr Tanushree Rao will be discussing the topic of abnormal uterine bleeding, including what abnormal uterine bleeding is, how a patient would typically present, the risks of the condition, the causes, how a GP can manage this condition and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Tanushree Rao.
Dr Tanushree Rao is an experienced Obstetrician & Gynaecologist providing care in Sydney’s Southwest. Tanushree is skilled in advanced laparoscopic surgery and experienced in all areas of Obstetrics and Gynaecology.
Dr Rao studied Medicine at the Rajiv Gandhi University of Health Sciences in India and went on to be granted the prestigious MRCOG at the Royal College of Obstetricians and Gynaecologists in London. Following this she completed her Fellowship of Royal Australian and New Zealand College of Obstetricians and Gynaecologists in Sydney. She then underwent an additional two years of advanced laparoscopy training after receiving a fellowship, which was recognized by the esteemed AGES committee in Australia.
Today, we’ll be discussing the topic of Abnormal Uterine Bleeding.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Tanushree, thanks for talking with us on Pod MD today.
Tanushree: Thank you for having me.
The topic of today’s discussion is Abnormal Uterine Bleeding. Tanushree, Can you describe for our listeners what Abnormal Uterine Bleeding is?
Tanushree: Sure thing. So abnormal uterine bleeding is a broad term that describes irregularities in the menstrual cycle that usually involves frequency, regularity, duration, and volume or flow. We need to now know what then is a normal menstrual cycle, isn’t it? So, this is 1 where the menstrual cycle is typically between 21 and 35 days.
A normal menstrual period generally last up to seven days, so anything that does not fit this definition, we tend to call it abnormal uterine bleeding, so it could be less than 21 days or the periods come you know more than 35 days or if the periods last more than 7 days and there are few other definitions that fit the bill as well. Say the woman has intermenstrual bleeding or post coital bleeding. All of this is also not considered normal.
How would a patient with Abnormal Uterine Bleeding typically present?
Tanushree: There are many presentations and I’m just going to start outlining them. So the first one would be bleeding or spotting between periods. Sometimes you can have bleeding or spotting after sex what we call post coital bleeding. Heavy bleeding during your periods. So, say there is bleeding that soaks through one or more tampons or pads every hour, or the bleeding that lasts for more than seven days, because remember how we discussed our initial definition. And then menstrual cycles that are longer than 35 days or shorter than 21 days.
So we have terms for these that we would use earlier, so oligomenorrhea and similar things, but these days all of this just comes under the bracket of abnormal uterine bleeding so that there’s no confusion regarding I guess terminology and most of us just understand by the description itself as to what the problem is.
Irregular periods in which cycle length varies more than 7 to 9 days. And even sometimes not, just having a period for three to six months as well. And sometimes we can see this in conditions such as PCOS etc. That is abnormal uterine bleeding as well, and of course the most important is bleeding after menopause. Now this can be even just pinkish discharge to brownish discharge or spotting and sometimes frank bleeding. All of this is what we call, you know, abnormal uterine bleeding and the presentations that they come with.
What are the risks of the condition?
Tanushree: The I would say, you know, I would cover this under a topic of how does it effect, so most of the women I see when they come with these complaints usually complain of interfering with their quality of life. So essentially it stops them from living their life to the fullest and that’s the main complaint.
Oh Doctor, I had to change pads. I was feeling so embarrassed I couldn’t go out to this party and you know, my parents got stained and essentially what it conveys to me is they are not able to carry on with their daily workings of the day. Now in some women they can bleed quite heavily and that can cause clinical anaemia, which can present with symptoms such as tiredness, dizziness, lethargy and generally feeling unwell.
Now, in severe cases, they may need iron infusion, and sometimes they can even need blood transfusion. Which reminds me, I actually had a patient with stage 4 endometriosis and a fibroid uterus whom I operated on last month, who would essentially come every month whenever she bled to the emergency department and when we would do our blood tests and her haemoglobin would be somewhere around, you know, the 50s or the 60s, and then she would need blood transfusion essentially every time she bled.
Which is why we did try a bit of conservative measures, but in the end she ended up with a hysterectomy. Now of course it depends on the age group as well and especially in post-menopausal women. It also could be a sign of something sinister like endometrial cancer, which is why we take any sort of bleeding or pinkish discharge in the post-menopausal age group quite seriously.
What are the treatment options?
Tanushree: Well, I would like to divide this question into two parts. One is investigation and the other is management. The first step of course is a clinical examination where we look at the cervix and vagina and it’s really important at this point to ensure the CSDs are up to date and we can take genital swabs as well and an STI screen that is the sexually transmitted infection screen after consent from the woman.
Investigation wise, we can do a full blood count followed by iron studies, which will give us an indication whether she’s anaemic along with iron deficiency or not. Now, in some circumstances we can also order extra tests like thyroid function tests, coagulation studies, and I do this especially in the young age group, just to rule out other causes that can cause abnormal uterine bleeding.
Meeting now, after all these blood tests, we usually follow that with a pelvic ultrasound, which is a baseline investigation and gives us a lot of information, especially if there are structural causes like polyps, fibroids or variances etc. Now once the course is found or in some cases not found, then we can classify them into different management plans.
The first step is usually medical, where we involve tranexamic acid, NSA, oral contraceptive pills, Marina, etc. The surgical management then depends on the age group, and it probably would be a hysteroscopy D&C or removal of the structural cause as such. And then the last option would be a uterine artery embolization, which can also be utilised depending on the course.
What are the causes?
Tanushree: So as of now, we tend to follow the latest classification according to FIGO, there are 9 main categories which they have come up with and they have a nice little acronym for us to remember as well. So it’s called palm coein, PALM-COEIN. Now this if you just manage to remember this acronym, we then can figure out all the possible causes for abnormal uterine bleeding. So P would stand for polyp, followed by adenomyosis, Leiomyoma, which is also called as fibroids, malignancy and hyperplasia. Coagulopathy for the C ,ovulatory dysfunction usually seen in the adolescent or the Peri menopausal age group. Endometrial for the E, iatrogenic and not yet classified. I usually just go through all these causes in my head when I take history, and I usually find that this saves me from missing out on any important cause that might contribute to the abnormal bleeding.
How can a GP manage this condition?
Tanushree: Initially the management can be done by medical methods, and by this I mean it really depends on how much bleeding the woman is having. You can divide that into acute bleeding or bleeding that is continuous but not yet causing, you know, anaemia or iron deficiency, I suppose. So for acute bleeding. If they are stable, one can easily manage as an outpatient. I usually would say try primolut which is also called norethisterone 10 milligrams three times a day. Or you can use a similar product which is called medroxyprogesterone acetate 20 or 10 milligrammes or 20 milligrammes 3 times.
Now, sometimes you can even use oral contraceptive pills at three times a day for at least seven days to get acute control over this bleeding. And of course these are all the hormonal methods that you can use. You can always top it up with tranexamic acid which is 1 gramme four times a day. Now, in rare instances, we can use other drugs like GNRH analogues, [inaudible], but I haven’t used them myself I have to be honest. I usually do get a lot of success just by using progesterone’s like [inaudible] or medroxyprogesterone acetate.
Now once you do get an initial, you know, control over the acute bleeding, then you would think of how do I maintain this, as in for a long-term maintenance programme. So all contraceptive pills, the DMP or the depot Provera injection which is given every three months implanon which is a rod that is inserted again, releases progesterone and has to be changed every three years.
Or you can insert a kyleena or a Mirena inside the uterus, which again releases micronized progesterone, and this this would be either every three years or five years, and that it would need an exchange.
What role does the GP play in the treatment of the condition?
Tanushree: Look GPs play a really important role because they are the first point of contact and most of the time they successfully managed abnormal uterine bleeding. So in the adolescent group, I would say you know try hormonal medication in the Peri-menopausal and postmenopausal group, the standard recommendation is to 1st get an endometrial biopsy. So that can take form in in in either through a people’s biopsy or a hysteroscopy D&C. So I would say these are the points when a GP can think of referring to a gynaecology. And of course, if there is a structural costs such as fibroids, polyps and abnormal pap smear, etc, please do not hesitate to refer them as well.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Abnormal Uterine Bleeding.
Tanushree: Oh, it was wonderful to be here. Thank you for having me. And to summarise, I would say the take home message points are mainly 1, don’t ignore post-menopausal bleeding and the of course the most common cause in these cases is atrophic vaginitis, but the more sinister cause is cancer or hyperplasia which we have to rule out.
And I think for you know, the other age groups such as adolescent and in the reproductive age group, do try hormonal medications first after ruling out contraindications and if that suits them, then that’s all they need. But don’t hesitate to refer them to a GYNAE or a gynaecologist, in case you think they would benefit from endometrial sampling or any further procedure that they need.
Thanks for your time and the insights you’ve provided.
Tanushree: All good thank you for having me.