Assessment of Irregular Bleeding in Primary Care. Mr Tyrone Carpenter MD MRCOG Consultant Obstetrician & Gynaecologist Poole Hospitals NHS Trust

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1 Assessment of Irregular Bleeding in Primary Care Mr Tyrone Carpenter MD MRCOG Consultant Obstetrician & Gynaecologist Poole Hospitals NHS Trust

2 Outline What s normal Differential Diagnosis Risk factors for cancer Investigations available Suggested investigations in primary care Summary

3 What is normal? Normal Abnormal Cycle length Duration of bleeding Volume of blood loss Regular days 3-7 days 30-40ml Irregular Greater than 7 days >80ml

4 The size of the problem 4-10% incidence of abnormal bleeding 5% of GP consultations 1998 UK 7 million in GP prescriptions

5 Differential Diagnosis (1) Endometrial Dysfunctional Uterine Bleeding Ovulatory Anovulatory Polyps Hyperplasia Carcinoma (IUCD / IUS)

6 Differential Diagnosis (2) Other genital abnormality Cervical Carcinoma Extra genital abnormality Thyroid dysfunction

7 Endometrial polyps

8 Proportion of Polyps by Age Uncommon < 35yo Over 1/2 between 35-55yo

9 Malignant Risk of Polyps Vast majority <55yo are benign

10 Endometrial Hyperplasia Simple -? Increased risk of Ca (2-3%) Complex - Slight increase risk Ca (3-4%) Complex Atypical 10-20% may have current underlying Ca 24-50% may develop Ca

11 Endometrial Carcinoma Around 10% of endometrial Ca occurs pre-menopausally

12 Risk Factors for Endometrial Carcinoma / Hyperplasia High BMI Nulliparity Late menopause Polycystic ovarian syndrome Personal or family history of Ca Colon / Breast / Endometrial / Ovarian Tamoxifen

13 Risk related to age <40yo DUB most likely by far Polyps next most likely by vast majority benign in this age group Only 1-3% of all endometrial Ca occurs <40yo Hyperplasia more likely than Ca by still uncommon in this age group Obviously risk factors play a part.

14 Investigation of Irregular History Examination Bleeding Speculum +/- smear if due Bimanual (limited use but can pick up big fibroids, ovarian cysts etc.) Investigations

15 Investigations available Pelvic Ultrasound scan Pipelle endometrial sample (or similar) Hysteroscopy + endometrial biopsy

16 Transvaginal Ultrasound Scan Advantages No risk V little discomfort Usually picks up polyps Disadvantages No histology

17 Transvaginal Ultrasound

18 Pipelle Endometrial Sampler Advantages Histology obtained (usually) Disadvantages May miss polyps Occasionally misses hyperplasia / Ca Sometimes fails Can be uncomfortable

19 Pipelle Endometrial Sampler

20 Hysteroscopy + Endometrial Biopsy Advantages Can identify (and treat) polyps Can identify Ca Disadvantage Requires hospital referral May need GA Can still miss some Ca

21 So who should be Ix and how far should we go in Primary Care? < 40yo with no risk factors no need to investigate as first line. If significant risk factors investigated as >40yo If fails medical treatment the investigation required

22 So who should be Ix and how far should we go in Primary Care? > 40yo requires investigation Stage of referral depends on local situation Perfectly reasonable to obtain a scan and take a pipelle (if properly trained) in primary care

23 Possible Results - Ultrasound Normal Undertake pipelle sample Polyp Identified / Suspected Refer

24 Possible Results - Histology Normal proliferative / secretory / menstrual endometrium Simple / Complex hyperplasia without atypia Complex atypical hyperplasia Carcinoma Insufficient for analysis

25 Action on abnormal histology Simple / Complex hyperplasia without atypia Commence 10mg Provera od and routine referal to Gynae Complex atypical hyperplasia Carcinoma Insufficient for analysis Either repeat or refer routinely Urgent Gynae referral

26 Summary Irregular bleeding is common The vast majority of women < 40yo will have no sinister pathology and don t require immediate investigation Most women >40yo will have no significant pathology but do require investigation USS and pipelle sampling can be undertaken in a primary care setting in most cases