Undergraduate course lectures in Gynecology ,prepared by Dr manal Behery ,assistant professor,faculty of medicine,Zagazig University

1. How to approach a case of
abnormal Vaginal bleeding
DR;MANAL BEHERY
Assistant Professor, Zagazig University
2013

2. Definition
Any uterine bleeding that is excessive in
amount ,duration or frequancy

3. classification
Organic
Systemic
Reproductive tract disease
Iatrogenic
Dysfunctional
Ovulatory
Anovulatory

4. Systemic Etiologies
Coagulation defects
Leukemia
ITP
Thyroid dysfunction
Liver disease

5. Reproductive Tract Causes
Gestational events
Malignancies
Benign
Atrophy
Leiomyoma
Polyps
Cervical lesions
Foreign body
Infections

6. Most Common Causes of
Reproductive Tract AUB
Pre-menarchal
Foreign body
Reproductive age
Gestational event
Post-menopausal
Atrophy

7. Iatrogenic Causes of AUB
Intra-uterine device
Oral and injectable
steroids
Psychotropic drugs

8. Dysfunctional causes
Dysfunctional uterine bleeding is
the most commom
After puberty
Before menopause
After labor or abortion

9. A practical approach (step 1)
History:
• Age(before puberty, reproductive age
,PM)
• Pattern of bleeding: cyclic or a cyclic
• Marital state: complication of pregnancy
• Drug intake ,hormonal ttt, HRT
• previous treatment
• last cervical smear

10. A practical approach (step2)
Physical examination
• General: obesity? thyroid? pallor?
pulse? Cachexia?
• Abdomen: palpable mass?
• Pelvis: cervical or vaginal lesion?
• Bimanual exam:uterine size
• Speculum :cervical lesion
• PR: rectum or parametrium

11. A practical approach(step 3)
investigation
Assessment of the endometrium (not needed for
women with very low risk of Ca endometrium)
• endometrial aspirate
• ultrasound pelvis (transvaginal) to assess
endometrial thickness
• Sonohystrography
• Hysteroscopy
• CT ,MRI for endometrial invasion

12. REFER (for endometrial
aspiration and TVS if
1. Over 40 years
2. high risk of endometrial carcinoma
3. genital tract lesion suspected (except
cervical polyp)
4. bulky uterus
5. previous medical treatment fail

13. If none of the above factors
Consider those investigations
cervical smear if sexually active and
last smear more than 1 year ago
CBC if menorrhagia
ultrasound pelvis if PV not possible
Thyroid function, coagulation profile
only when history suggestive

14. A practical approach (step4)
medical ttt
For women under 40 with no suspicion of
organic lesions either
Hormonal (for irregular bleeding as well
as menorrhagia)
combined OC
progestogen only (21 days needed)
Non-hormonal (for menorrhagia)
NSAID
antifibrinolytic agent

15. Choice of medical treatment for
menorrhagia
NSAID: 30% decrease in blood loss ,relieve
dysmenorrhoea as well
Antifibrinolytic (transamine): 50% decrease
Combined OC: effective but need to take through
out the month, effective contraception as well
Progestogen only: less effective, need 21 days, not
effective contraception
Haematinics: if anaemic
combinations can be used

16. When to consider medical
treatment as failure?
• Failure to relieve patient’s symptoms
after 3 months
• Remains anemic after 3 months

17. Step 5 When to refer?
• Over the age of 40
• High risk of endometrial Cancer
(obesity, DM, PCOD)
• Uterus > 10 week size or irregular
• Cervical pathology suspected
• No response to medical treatment

18. Other modalities of treatment
Levonorgesterol releasing IUCD (Mirena)
Endometrial ablation
Hysteroscopic removal of polyps or
submucous fibroids
Conventional treatment is hysterectomy

19. Case1
A 15 year old girl with irregular heavy
periods presents at your clinic.
menarche at the age of 13 and since then
is having unpredictable irregular periods
with prolonged bleeding every 2-3
months.
She is slightly overweight for her height.

20. Most likely diagnosis?
Anovulatory Dysfunctional uterine bleeding the
commonest cause in 95%
Initial cycles are anovulatory
Regular ovulation takes 1-2 years

21. Differntional
Diagnosis
Dysfunctional bleeding
Bleeding disorders -ITP,VWD etc
Endocrine causes
Medications
Local pathology -TB, FB, malignancies
No further significant features are found
on history or clinical examination.
What is the next step?

22. Investigations
Haematological
 Full blood count and peripheral
smear Platelet count
 Coagulation screen If indicated
Endocrine
 TFT, PRL
Ultrasound

23. What if anovulatlon persists
for more than 4 years-
chance of spontaneous correction is
low
Likely to be frank PCOS

24. Case2
A 34 year old lady complaining of
increasingly heavy periods since the
last one year attends your clinic.
She has two children 10 and 8 years
and underwent laparoscopic
sterilization 4 years back.
She finds that the bleeding is so heavy
that it interferes with her daily ' routine

25. Case cont,
History of regular heavy periods
Speculum and bimanual examination
normal
Recent cervical smear normal
Hb level 9 gm/ 100 nil

26. What is the next step
Organic pathology to be ruled out (Fibroids
and adenomyosis (
Rule out Pregnancy complications
Rule out endometriosis and pelvic Infection

27. IS coagulation profile and
endocrine panel a routine?
Testing for endocrine problems and
bleeding disorders not routinely
recommended
unless there are specific pointers in
the history

28. Is routine D&C or endometrial
sampling needed?
Not Indicated this age as first line management
If a woman has regular cycles
Probability of an abnormal endometrial histology
in a woman under 40 with DUB and regular
cycles is <1%

29. Indication for first line
endometrial sampling
Irregular periods with obesity and other
features of PCOS as they are candidates
at high risk for endometrial cancer at a
young age
Risk of cancer increases to 14%

30. What is the most
likely diagnosis
Ovulatory DUB or
Idiopathic menorrhogia

31. What next?
Confirm diagnosis or Idiopathic menorrhagia
Check for cycle irregularity, Intermenstrual or, postcoltal
bleeding
Woman With failed first Iine medical management are
more Iikely in have intrauterine pathology and so TVS
arid If needed hysteroscopy and endometrial sampling
are Indicated (RCOS guidelines)

32. TVS
polyps
submucous fibroids
Endometrial hyperplasia An endometrial
Thickness of 12 mm is used as the cut off
paint for endometrial hyperplasia on TVS
(RCOG)
Optimal time !s the proliferative phase.

33. Sonohysterography
TVS may miss small polyps
Difficult to distinguish from thickened
endometrium
SHG helps in accurate diagnosis

34. Endometrial
sampling
All women with persistent menorrhogia
To diagnose or exclude endometrial
carcinoma or hyperplasia
Probability of abnormal histology < 1 %
in this age with regular cycles

35. Sampling How?
Endometrial aspiration
Conventional D&C
Hysteroscopy and directed biopsy

36. Case3
A 47 year old woman gives a 2 year
history of irregular periods.
She has always had regular cycles until
3 years ago.
She has three children all delivered
normally.

37. Case cont,
 No significant finding in the histor
 On examination she is a little overweight
 Not anaemic
 Pelvic examination reveals a normal sized
anteverted mobile uterus
 Cervical smear is normal

38.  Anovulatary dysfunctional bleeding
Common at the extremes of reproductive life
But malignancy is to be ruled out
Endometrial sampling a must to detect
endometrial carcinoma and hyperplasia
What is the likely diagnosis?

39. The approach to DUB differs in the different age
groups and in particular depends on whether the
bleeding is cyclical or not.
The current RCOG recommendations in
premenopausal women with regular cycles is to
delay endometrial sampling till medical
management has failed.
Also the numbers of hysterectomies being done for
normal sized uteri are coming down with
Increasing acceptance of Mirena and endometrial
ablation

40. Case 4
Mrs. JP Age 56 Para 1,Complains of a
period that has been “going on for 2
weeks” with pain
WHAT ARE THE POSSIBLE CAUSES?

41. Mrs. JP Differential
Diagnosis
Endometrial Pathology
 Carcinoma
 Benign eg Polyp
Cervical Pathology
Other genital tract pathology
 Ovarian Ca
 Trauma
Dysfunctional Uterine Bleeding
Blood dyscrasia

42. what additional information
do you require?
Usual menstrual pattern
Recent menstrual cycles and LNMP
Estimate of blood loss
Description of the pain
Use of hormones - COC or HRT
Pap & Gynae History
Risk factors for endometrial Ca
Sexual, contraception & social history

43. Mrs. JP Additional
History
Usual cycle
Recent cycles & LNMP
Estimate of blood loss
Description of the pain
Use of hormones - COC
or HRT
Pap & Gynae History
Risk factors for
endometrial Ca
Sexual history etc.
Monthly until 6m ago
Some early and some late.
Skipped one month. This period
3w late
Has used 3 packets pads, some
3’’ clots. “Flooding”
“Like labour”
Nil
Regular Paps – NAD. One CS
and postpartum curette. Took
pill for 10 yrs then separated
Infertility. Hypertension. Obese
Celibate since separation

44. What Physical Exam Required
for this patient?
Signs of anaemia
Signs of endocrinopathy
 Thyroid
 Androgen excess
Examine the cervix
 ?Pap or ThinPrep
 Look for cervical mucous
 Is the cervix open?
Uterine size and regularity
Pelvic tenderness or adnexal mass?

45. Result of Physical Exam
Signs of anaemia
Signs of endocrinopathy
 Thyroid
 Androgen excess
Examine the cervix
 ?Pap or ThinPrep
 Look for cervical mucous
 Is the cervix open?
Uterine size and
regularity
Pelvic tenderness or
adnexal mass?
Pale. PR 96/min
Male type hair
distribution
Intact but patulous with
abundant clear mucous
NAD
NAD

46. DO YOU SEND THIS
PATIENT FOR SCAN?
Yes
Both transabdominal and transvaginal
scan is required

47. Mrs. JP Scan Report
“. Abdominal and transvaginal scans were performed.
The uterus is enlarged by multiple fibroids the largest
of which measures 2.5 cm in diameter. However,
there is no distortion of the endometrial cavity which
measures 17 mm.
. The right ovary is mildly enlarged with a volume of 40
cc and the left ovary contains a cyst measuring 2.8 x
2.7 cm.
This was evaluated with colour Doppler and no
abnormal vascularity noted.”

48. DO YOU SEND THIS
PATIENT FOR BLOOD
TESTS?
Yes
WHAT TESTS WOULD YOU ORDER?
HB %
S. Ferritin
Pap smear
TSH

49. Mrs. JP Pathology
Results
HB 90 Microcytic and hypochromic film
S. Ferritin – 5
Pap smear + ThinPrep NAD “but only scanty
squamous cells are present
TSH - normal

50. what would you prescribe for
this patient?
Rx Tabs Primolut 5 mg TDS for 10 days
Ferro-tonic– one daily
Maybe Nurofen 1-2 Q4-6H

51. Abdominal CT scan?
Immediate D&C?
Hysteroscopy?
Saline sonography?
Endometrial biopsy?
Hysterectomy?
No
There are better options
This is one that can be
performed as an outpatient
Maybe – but best for delineating
polyps
Pipelle endometrial sampling is
the best option
Only required if cancer of the
endometrium is diagnosed
Does this patient require?

52. Case 5
A 66-year-old nulliparous woman who
underwent menopause at 55 years complains
of a 2-week history of vaginal bleeding.
Prior to menopause she had irregular
menses. She denies the use of estrogen
replacement therapy.
Her medical history is significant for diabetes
mellitus controlled with an oral hypoglycemic
agent.

53. On examination
90kg weight , height 5 ft,
blood pressure 150/90 mm Hg, and
temperature is 99°F (37.2°C).
The heart and lung examinations are normal.
The abdomen is obese, and no masses are
palpated.
The external genitalia appear normal, and
the
normal sized uterue without adnexal masses

54. ➤ What is the next step?
Perform an endometrial biopsy.
➤ What is your concern?
➤ Concern: Endometrial cancer

55. A 60-year-old woman presents to her
physician’s office with postmenopausal
bleeding. She undergoes endometrial
sampling, and is diagnosed with endometrial
cancer.
Which of the following is a risk factor for
endometrial cancer?
A. Multiparity
B. Herpes simplex infection
C. Diabetes mellitus
D. Oral contraceptive use
E. Smoking

56. A 48-year-old healthy postmenopausal
woman has a Pap smear performed,which
reveals atypical glandular cells. She does not
have a history of abnormal Pap smears.
Which of the following is the best next step?
A. Repeat Pap smear in 3 months
B. Colposcopy, endocervical curettage,
endometrial sampling
C. Hormone replacement therapy
D. Vaginal sampling

57. A 57-year-old postmenopausal woman with
hypertension, diabetes,and a history of PCO
complains of vaginal bleeding for 2 weeks.
The endometrial sampling shows a few
fragments of atrophic endometrium.
Estrogen replacement therapy is begun.
The patient continues to have several
episodes of vaginal bleeding 3 months later.

58. Which of the following is the best
next step?
A. Continued observation and reassurance
B. Unopposed estrogen replacement
therapy
C. Hysteroscopic examination
D. Endometrial ablation
E. Serum CA-125 testing

59. A 52-year-old woman, who has hypertension
and diabetes, is diagnosed with endometrial
cancer.
Her diseases are well controlled. Her
physician has diagnosed the condition as
tentatively stage I disease (confined to the
uterus).

60. Which of t e following is the most
important therapeutic measure in
the treatment of this patient?
A. Radiation therapy
B. Chemotherapy
C. Immunostimulation therapy
D. Progestin therapy
E. Surgical therapy

61. THANK YOU