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Which of the following tests are required for a 45-year old Para 4 who is suffering from prolonged vaginal bleeding at intervals of 3 to 6 weeks? She has a normal sized uterus to clinical evaluation.
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Ultrasound pelvis Full blood count Pap smear Coagulation profile Liver function tests Serum Iron Serum ferritin Endometrial biopsy CT pelvis and
abdomen Serum CA125
Renal function tests Office hysteroscopy TSH Thyroid function tests Serum FSH & LH Serum beta HCG Serum oestradiol Serum prolactin Serum Progesterone D&C uterus None of the above
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Ultrasound pelvis To evaluate the
endometrium.If diffusely thickened it suggests that a Pipelle biopsy would be useful
Exclude submucous fibroid(s)
Other fibroids of less interest because the uterus is not enlarged
Ovarian imaging useful
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Full blood count Check HB
RBC’s may show signs of chronic blood loss
Platelet count
Excludes major blood dyscrasia
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Pap smear This is not a test for
cervical cancer. If that is suspected after visual inspection and palpation then biopsy is required
Should be done if not previously done or overdue
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Coagulation profile A clotting disorder is very
rarely the cause of this problem
This is not a first line test
Ask about “other bleeding and bruising”
Check family history
Warfarin but not aspirin or NSAID may be relevant
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Liver function tests Renal function tests
This patient requires a blood test and adding these two to a FBC is sensible
Renal failure may present with menstrual disorder
Liver failure can cause a coagulopathy
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Serum Iron Serum ferritin
Not first line tests but may be required if anaemia is a problem
Serum ferritin is favoured by NZ DOH as a criterion for the Mirena for which this patient may be a candidate
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Endometrial biopsy If there is diffuse widening
of the endometrial echo a simple Pipelle sampling will exclude cancer of the endometrium with >97% sensitivity
Some pathologists would prefer that you do this before administering progestins
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD CT pelvis and
abdomen
Not unless you (or the patient or the radiologist) are prepared to pay for it!
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Serum CA125 Not required
It would be indicated if the ultrasound disclosed a suspicious ovarian mass
But it is not recommended as a screening test for ovarian cancer
I sometimes use a menstrual phase CA125 for a patient with possible endometriosis
But only when laparoscopy is not readily available
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD TSH Thyroid function
tests
Thyroid dysfunction may present as a menstrual problem
Look for other symptoms and signs
TSH is the best screening test
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD Serum FSH & LH Serum beta HCG Serum oestradiol Serum prolactin Serum Progesterone
Although anovulation is the most likely diagnosis endocrine studies are rarely used or useful
Do not use a high FSH to label the patient as “postmenopausal”
Ask about hot flushes instead
Always exclude pregnancy
A 45-year old Para 4 with prolonged vaginal bleeding every 3 - 6 weeks? Examination - NAD D&C uterus A 21st century
gynaecologist would favour ultrasound +/- saline ultrasonography or Pipelle sampling or office hysteroscopy
45 yo Para 4 with vaginal bleeding every 3 – 6 weeks. Bleeding now for 11 days. Ultrasound NAD. No symptoms or signs of acute or chronic blood loss. What is the best way of stopping the bleeding?
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD. How best to stop the bleeding? Oral oestrogens IV Oestrogen Oral Progestin IM Depot Provera Oestrogen and
Progestin by mouth Tranexamic acid
(Cyklokapron) Mirena IUS Danazol D&C uterus
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
Oestrogens by mouth
This patient may already be hyperoestrogenic
There is a risk of thromboembolism
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
IV Oestrogens IV Premarin said to be very effective
There is a risk of thromboembolism
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
Oral Progestin Creates a decidual-like
endometrium
Use Norethisterone 5 -10 mg Q6H til bleeding stops then BD for 10 – 12 days
Has progestogenic and oestrogenic actions
There is a theoretical risk of thromboembolism
Warn the patient about withdrawal bleeding
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
IM Depot Provera Unpredictable in onset
Unpredictable in duration
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
Oestrogen & Progestin by mouth
Using any form of oral contraceptive pill may be effective
However, BD or TDS dose required my be an unacceptable risk of thromboembolism
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
Tranexamic acid (Cyclokapron)
Will reduce menstrual flow in 85% of women but it is not the drug of choice to stop bleeding here
There is no risk of thromboembolism when used according to directions i.e. 500 – 1000 mg TDS or QID
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
Mirena IUS A very good option
Circulating concentration of d-norgestrel equivalent to 2 tablets of Noriday per week
Troublesome irregular bleeding can occur for 6 – 16 weeks
45-yo P4 with vaginal bleeding for 11 days. Examination & ultrasound- NAD.
Danazol Would probably work
Indicated in the management of menorrhagia
Expensive
Has more androgenic side- effects than progestins