abnormal vaginal bleeding. veterans health administration objectives 2

Abnormal Vaginal Bleeding

VETERANS HEALTH ADMINISTRATION

Objectives

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What is the average blood loss during a typical menstrual cycle?

A. 20 ccB. 40 cc C. 60 ccD. 80 cc

Question…

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Case Study #1

What should be the first

question(s) on your mind?

Case Study 1

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LMP, contraception, menopause, hysterectomy• Early pregnancy bleeding may be life-

threatening• Many women unaware of pregnancy• Always consider her to be pregnant

and rule that out first─ Urine test detects pregnancy 2

wks after conception─ Serum test detects about 1 wk

after conception─ All clinics caring for women should

have point-of-care (on-site) urine pregnancy tests; urine results faster, newer tests highly accurate

Check for hypotension, tachycardia, orthostasis, fever, ill appearance.

Remaining assessment points discussed later.


Hemodynamically Unstable?

YES urgent evaluation6


Pregnant?

POSITIVE PREGNANCY TEST Urgent evaluation

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Answer

Now we’ll explore normal menses, including average blood loss.

What is the average blood loss during a typical menstrual cycle?

A. 20 ccB. 40 cc C. 60 ccD. 80 cc

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First part of cycle:•Estrogen dominant endometrium builds

Ovulation occurs 14 days before onset of the next period

After ovulation, corpus luteum is formed and creates progesterone.

Second part of cycle:•Progesterone dominant endometrium is stabilized

Menstrual Cycle


Correlation Between Cycle Duration and Bleeding

• Shorter intervals between cycles endometrium has less time to proliferate shorter duration of bleeding

• Longer intervals between cycles endometrium proliferates longer periods of bleeding

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Back to the case of our 42 yo veteran with onset “heavy” vaginal bleeding and cramping. Why does heavy bleeding occur?

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What Causes Ovulatory Bleeding?

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Uterine Lesions•Structural lesions can cause regular, heavy bleeding

•Fibroids or other lesions that are in or near the lining, in particular, can cause heavy bleeding

•Fibroids usually cause regular, heavy bleeding but can also cause intermenstrual bleeding

•Other lesions, such as polyps, or even inflammation and infection can also cause heavy bleeding

•Endometritis (infection in the uterine lining, is particularly prevalent during post-partum or post-procedure periods

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What Causes Anovulation andAnovulatory Bleeding?

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•In normal menstrual cycle, endometrial lining builds up with estrogen and stabilizes with progesterone

•If ovulation doesn’t occur, progesterone isn’t produced

•Thus, endometrium continues to build, isn’t stabilized, and begins to slough off

•A woman might experience irregular bleeding which can be heavy or light

Anovulation

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Back to the case…

42-year-old veteran

What more should you ask?

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Ask about abdominal or pelvic pain:•Related to worsening menstrual cramps with increased flow? •Something serious like an ectopic pregnancy (with positive pregnancy test)?•Query pain duration, constant or cyclical, location (midline or lateral), sudden onset or gradual

Ask about menstruation patterns•What is normal for her?•History of irregular/heavy menses?

Ask about other symptoms:• Related to anemia: SOB, light-

headedness, syncope, fatigue • Related to infection: fever,

chills18


Estimating Blood LossTry to obtain objective evidence• For triage, try to quantify bleeding by number of pads the woman

is using, or ask her to compare it with her normal menses.− Typical definition of profuse bleeding: soaks large sanitary pad or

tampon every hour or two, for two or more hours− Prolonged uterine bleeding = bleeding for >7 days

• For diagnosis, pad/tampon counts are unreliable. Studies show 50% of women complaining of heavy bleeding have normal blood loss.

Estimates of blood loss taken by history are not reliable, though you may get a sense of changes in pattern. CBC and ferritin can help figure out if she has ongoing, significant blood loss, but these may be normal in a patient with acute blood loss only.

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Our 42 yo veteran with onset “heavy” vaginal bleeding…

It was decided that she should be seen by the provider

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Exam Room Set-UpSpecifics about room set-up and assisting during the exam is covered in another session, but in general, necessary equipment includes:•Table with foot rests, privacy curtain, lockable door•Gown and cover sheet•Gloves for provider and assistant•Surgical lubricant•Speculum appropriate for patient: Graves (small, med, large) or Pederson•Light source•Supplies for Pap and GC/chlamydia tests•Procto swabs (also known as fox swabs)•Monsels /silver nitrate sticks if recent gynecological procedure•Pad / panty liner / tissues for post-procedure•Female chaperone is required; assistant may be used in this role•Privacy

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Further Evaluation

Nurses are often asked to explain at least the basics of pelvic US and endometrial biopsy procedures…

Specific Treatment – MedicationsNSAIDs (e.g., ibuprofen, naproxen)

Hormonal contraceptives (e.g., OCPs, Depo)

Pelvic Ultrasound

Endometrial Biopsy

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Image used with permission from Krames StayWell

Pelvic UltrasoundTransabdominal

What is it?Test to look at organs and structures in the pelvis.

How is it done?A “transducer” sends out sound waves that bounce off body structures like an echo to create a picture. A gel, spread on the pelvis, allows smooth movement of the transducer over skin and eliminates air between the skin and transducer to improve sound conduction. A typical exam takes 30-60 minutes.

Are there risks?No radiation exposure. Usually painless. May have some mild discomfort as the transducer is guided over a full bladder.

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Pelvic UltrasoundTransvaginal


What is it?Test to look at reproductive organs.

How is it done?A probe, covered with a condom and surgical lubricant, is inserted in the vagina. It sends out sound waves that bounce off body structures to create a picture.

What are you looking for?Abnormal findings, such as fibroids. Thickness of the endometrial stripe.

Risks?No radiation exposure. Generally painless, but pressure from the probe could be uncomfortable. Patients with vaginal atrophy/ dryness might be uncomfortable.

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Endometrial BiopsyWhat is an endometrial biopsy?Tissue is taken from uterine lining (endometrium) and checked for abnormal or malignant cells.

How is it done? Office-based, no sedation, typically pre-medicate with an NSAID.

Patient will lie down with feet in foot rests. Provider will insert speculum to visualize the cervix. Cervix is cleaned with antiseptic and then grasped with a tenaculum to stabilize the uterus. Cervical dilator may be used to open cervical canal if there is stenosis. Small, hollow, plastic tube is gently passed into uterine cavity. Gentle suction removes sampling of the lining.

Patient might be taken to OR for HSC, D&C with anesthesia. However, office procedures are safe – we have seen decreases in morbidity and mortality since office-based endometrial biopsies were introduced.

When is it recommended?For abnormal bleeding…heavy or prolonged. Generally women >40.

What are you looking for?•Cause of abnormal bleeding•Checking for endometrial cancer (very accurate for diagnosing endometrial cancer)

What are potential complications? •Are rare; generally a very safe procedure•Infection, bleeding, cramping•Perforation of the uterus

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Endometrial Biopsy



Back to our 42 yo veteran with “heavy” vaginal bleeding……

Whether or not fibroids are causing the heavy bleeding is not certain – it could be just changes in her cycle as she

approaches the perimenopausal years.

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Vaginal bleeding in a woman with a new positive pregnancy test may be due to:

A. Threatened abortionB. Incomplete spontaneous abortionC. Ectopic pregnancyD. Vaginal laceration/abrasionE. All of the above

Question…

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Case Study 2

What are ALWAYS your two primary

triage concerns?

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1) Is she hemodynamically stable?

2) Is she pregnant?

After establishing status of her hemodynamic stability and pregnancy, you can move on to a more detailed pain assessment, assessment of her menstrual patterns, other symptoms, and estimated blood loss.

Note that this evaluation follows the same steps as the evaluation for the previous patient.30


Case Study 2 Continued….

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What Diagnoses Do You Need to Have in Mind?

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Causes of First Trimester Bleeding

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Vaginal bleeding in a woman with a new positive pregnancy test may be due to:

A. Threatened abortionB. Incomplete spontaneous abortionC. Ectopic pregnancyD. Vaginal laceration/abrasionE. All of the above

Answer

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Back to the case of our 33 yo Veteran with irregular vaginal bleeding… Next steps for evaluation

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Does recurrent bleeding or spotting between periods require further evaluation?

A. YesB. No

Question…

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What are possible causes?

Case Study 3

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Causes of Intermenstrual Bleeding

Many of these may be evident on exam, so a complete H&P is the next step.


Answer

Does recurrent bleeding or spotting between periods require further evaluation?

A. YesB. No

As we have just reviewed, physiologic bleeding is a diagnosis of exclusion. Therefore, a pelvic exam with cervical cancer screening is the MINIMUM evaluation this patient will need. Likely that she will need additional evaluation beyond that.

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What questions

should you ask?

Case Study 4

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Emphasis is a bit different when assessing postmenopausal women… with vaginal bleeding• Pregnancy

− Less concern about pregnancy as women get older− HOWEVER, if a patient is still menstruating, there is a

chance of pregnancy… we have seen pregnancy in women who are in their early 50’s

• Hemodynamic stability− Difficult to assess hemodynamic stability over the phone− HOWEVER, this patient reported small amounts of

bleeding. If indeed there is little bleeding, hemodynamic instability is less of a concern.

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Post

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Poss

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Primary goal of evaluating postmenopausal bleeding is to exclude malignancy

Different approach may be used for

patients on hormone replacement therapy

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Key Points for Vaginal Bleeding

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AuthorsLaure Veet, MDWomen’s Health Services, Office of Patient Care Services, VHA Central Office

Deborah Ingram, PhD, ARNP-BCMalcom Randall VAMC, Gainesville, FL

Melissa McNeil, MD, MPHVA Pittsburgh Health Care System

Linda Baier Manwell, MSUniv of Wisconsin-Madison Division of General Internal Medicine

Molly Carnes, MD, MSUniv of Wisconsin-Madison Center for Women’s Health Research

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abnormal vaginal bleeding. veterans health administration objectives 2

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