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Abnormal Uterine Bleeding

  

There are many different causes of abnormal bleeding.


Appropriate COVID-19 Pandemic Management of Gynaecological Problems (courtesy of Mr Feras Izzat UHCW April 2020)
Heavy Menstrual Bleeding (HMB)

Initial remote management and reassurance

History with a focus on severity and anaemia symptoms

Oral medication if no / mild symptoms of anaemia

Referral to secondary care for further management

  • HMB is torrential and / or prolonged
  • Ongoing HMB resistant to oral treatments and considered unmanageable
  • Severe anaemia HMB
  • Emergency Gynaecology Clinic – Phone / Video consultation (if exam / scan / FBC done)
  • IV iron or transfusion
  • High dose progesterone
  • GnRH analogues if refractory to initial oral meds (3 monthly injection or nasal)
Inter Menstrual Bleeding (IMB)

History and reassure by remote consultation

Most are dysfunctional and cancer is a rare

Pregnancy should be excluded

Where STI or genital tract cancer is considered negligible:

  • Reassurance
  • Observation with phone follow up
  • Change in hormonal contraceptives in current users
  • Trial of hormonal contraceptives in non-users

Attend for a pelvic examination in primary care IMB if:

  • Risk of sexually transmitted infection (take genital tract swabs)
  • Cervical cancer is suspected
  • Associated post-coital bleeding and / or offensive vaginal discharge
  • Ultrasound if possible

Referral secondary care IM:

  • Cervical cancer is suspected on pelvic examination (2WW)
  • Endometrial cancer is suspected
Post Menopausal Bleeding

Initially remote communication

Confirm the symptom

Determine if they have any symptoms of COVID-19 (Any woman with suspected or confirmed COVID-19 inform them that they will not be seen in secondary care until they are no longer infectious  – 14 days from the onset of symptoms)

2WW referral to be made

Assess whether hospital assessment can be deferred for COVID-19 vulnerable patients (SPL)

This risk needs to be balanced against the risk of delay in diagnosis or exclusion of a gynaecological cancer on a case by case basis.

Post Coital Bleeding
  • Initially managed by remote consultation
  • Reassurance  that cervical cancer extremely unlikely if they have an in-date negative cervical screening test
  • If STI risk they should be seen in primary care or a Sexual Health Clinic for further investigation and management
  • Women who do not have an in-date negative cervical screening test need to be seen for a speculum examination to exclude cervical cancer and for a smear to be taken if possible
2WW

Referrals to continue

All will be triaged by consultant

Letters will be sent highlighting any rejections / postponement with reason

Early Pregnancy Assessment Unit
  • Triaged by phone for any symptoms of COVID
  • If have to attend – alone
  • Exclude ectopic pregnancy
  • Uncertain viability of intrauterine pregnancies will not have scan follow up
  • Management of ectopic and miscarriage will favour medical / conservative
  • Surgery only if absolutely necessary
Contraception

Combined hormonal contraception / progesterone only pill

Phone consultation and prescription for current users 6-12m without the need for routine checks

Depot medroxyprogesterone acetate (DMPA)

Depo Provera: recommend swap to desogestrel (can be started without extra precautions up to 14w from last injection)

Sayana Press: current or past users can have 12m supply by remote consultation

Implants

Etonogestrel implant (ENG-IMP) can stay in for an extra year / POP if wants

If more than 4 years offer POP – Can stay in if expired and no need for contraception if don’t want to get pregnant

Intra Uterine System IUS (Mirena / Levosert)

Replacement can be deferred for an extra year / POP can be added without the need to see

All women over age 45 years at insertion can rely on the 52mg IUS for contraception until age 55

INDIVIDUALS USING THE 52mg LNG-IUS FOR ENDOMETRIAL PROTECTION AS PART OF HRT MUST HAVE THE IUS CHANGED AT 5 YEARS (OR STOP OESTROGEN, OR SWITCH TO A COMBINED HRT PREPARATION

Other LGN-IUS – POP / Condoms

Copper IUCD

5 – 10 years – Condoms/POP

Some evidence to leave for 12yr

Over 40 who have any copper IUCD protected till 55

Hormone Replacement Therapy HRT

Remote consultations

Repeat prescriptions

Urogynaecology

No new face to face appointments

Remote consultations – lifestyle changes

Vaginal ring pessaries – can be postponed for 3 -6 months from last replacement due

Other pessaries – 3 month delay

Bleeding / pain / urinary retentions will be seen

Endometriosis

Remote consultations continue with advice to patients and GP’s

Current patient information link:  https://www.endometriosis-uk.org/coronavirus-covid-19- and-endometriosis

Cancer

2WW clinics continue (remote and face to face)

All surgery transferred to BMI site

Prioritisation of surgery undertaken at MDT with the low priority deferred for 10-12 weeks

NON COVID-19 ADVICE & ARRANGEMENTS
Abbreviations
  • MDC -Menstrual Disorders Clinic UHCW
  • CAS – Clinical Assessment Service / Community Gynae Clinics (City of Coventry Health Centre)
  • Both clinics have facilities for ultrasound, so there is no need to arrange before referral
  • HMB – heavy menstrual bleeding
  • DUB – dysfunctional uterine bleeding
  • PCB – post coital bleeding
Heavy & Abnormal Uterine Bleeding Guidance (use link on right panel)

Uterine enlargement / pain       – page 1

Regular heavy bleeding            – page 2

Irregular heavy bleeding           – page 3

Post Coital Bleeding (updated) – page 3

*PCB needs a 2WW referral only of the cervix appears abnormal on examination (do not refer directly to colposcopy)

PCB is now to be referred to the MDC (Menstrual Disorders Clinic) or Community Consultant Clinic primarily for a TVS and examination of the cervix, as the majority of these would be symptomatic due to endometrial shedding or some other functional menstrual problem.

If a colposcopy is required a referral will be made from Secondary Care.

If the cervix appears suspicious on examination in Primary Care a 2WW referral should be made.

Post menopausal bleeding       – page 4

2 week wait referrals                 – see separate link

Mirena coil fitting

If your surgery does not offer a service for Mirena coil fitting, then the patient can make their own arrangements by phoning Integrated Sexual Health Services on 0300 020 0027.

Alternatively, where additional gynaecological factors need assessment, you can refer via NHS e-referral to “Community Assessment Service/ Community Gynaecology Clinic” at City of Coventry Health Centre.

Hysterectomy

It is important that healthcare professionals understand what matters most to each woman and support her personal priorities and choices.

Hysterectomy should be considered ONLYwhen:

  • Other treatment options have failed or are contradicted
  • There is a wish for amenorrhoea
  • The patient (who has been fully informed) requests it and no longer wishes to retain her uterus and fertility.

 

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