Dr Anne Connolly discusses how women with abnormal uterine bleeding can be managed, including when examination and investigations are required

Connolly_Anne

Dr Anne Connolly

Read this article to learn more about:

  • types of abnormal uterine bleeding (AUB)
  • when women with AUB need to be seen, examined, and investigated and when management can be remote
  • how guidance on the management of AUB in the COVID-19 pandemic may provide future learning opportunities.

Implementation actions for STPs and ICSs

Read this article at: GinP.co.uk/455700.article

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After reading this article, ‘Test and reflect’ on your updated knowledge with our patient scenarios. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

Menstrual concerns are a frequent complaint in primary care. Each year, 1 in 20 women aged 30–49 years consult their GP because of heavy menstrual bleeding (HMB),1 and many experience non-menstrual bleeding, including unscheduled bleeding on hormonal contraception and hormone replacement therapy (HRT). The challenge for primary care clinicians is to determine how many of the women who contact the clinic with ‘period problems’ need to be seen, examined, and investigated, and when management can be organised remotely. 

The key to delivering care for women with abnormal uterine bleeding (AUB) is a basic understanding of the menstrual cycle and an appreciation of endometrial risk factors obtained from the clinical history. Management choices can be determined by the information obtained from the woman’s history, alongside an individual holistic risk assessment.

In May 2020, the Royal College of Obstetricians and Gynaecologists (RCOG), the British Society for Gynaecological Endoscopy (BSGE), and the British Gynaecological Cancer Society (BGCS) issued joint guidance on the management of AUB in the COVID-19 pandemic.2 The guidance was modified by the Primary Care Women’s Health Forum for use in primary care, with an additional section on unscheduled bleeding on HRT.3 Although these recommendations were initially written and agreed for a time when opportunities for face-to-face contact and specialist referrals were reduced, they enable us to rethink how we manage a woman’s bleeding concern, including when and if examinations and investigations are required.

The symptoms of AUB overlap; however, for each complaint, the guidance outlines an initial management recommendation with a reminder of the ‘red-flag’ symptoms requiring urgent referral.2 These recommendations are published as guidance and clinical judgement is essential, considering each case on an individual basis with a reminder that the patient’s needs are paramount and examination may be beneficial to reduce anxiety.

A woman’s health concerns must be valued and appreciated when undertaking a remote consultation. Many women tolerate bleeding problems as they perceive that they are normal. The trigger for making an appointment is usually an embarrassing episode, such as ‘flooding’, or a ‘cancer scare’, such as postcoital bleeding (PCB) or postmenopausal bleeding (PMB).

Heavy menstrual bleeding

Heavy menstrual bleeding is a frequent concern and one that has a significant effect on a woman’s quality of life.1 A relevant clinical history is essential (Box 1); however, the risk of malignancy in premenopausal women with HMB but without significant risk factors is negligible.4 The woman’s history should determine the severity of the concern, whether she is likely to be anaemic, and any likely cause.

Box 1: History for heavy menstrual bleeding

  • How is HMB affecting the woman physically, emotionally, and socially?
  • Is this a single episode or has this been a concern for a while?
  • Is she noticing symptoms of anaemia (breathlessness or excessive tiredness)?
  • Does she have any non-menstrual (intermenstrual or postcoital) bleeding?
  • Is she experiencing dysmenorrhoea or pelvic pain?
  • Is she using or does she require contraception?
  • Could she be pregnant?
  • Is she at risk of a sexually transmitted infection?
  • Has she completed her family?
  • Is she up to date with her cervical screening?
  • Does she have a history suggestive of a clotting disorder?
  • Is she taking anticoagulants?
  • Does she have any risk factors for endometrial hyperplasia (e.g. obesity, diabetes, or polycystic ovary syndrome)?
  • Does she have any significant family history?

HMB=heavy menstrual bleeding

NICE published NICE Guideline (NG) 88 on Heavy menstrual bleeding: assessment and management in March 2018, with an update in March 2020.1 It recommends that all women with HMB have a full blood count test to exclude the insidious onset of anaemia that persistent excessive bleeding can cause. A history of heavy bleeding and acute blood loss requires examination and possible hospital admission before alternative approaches to management are considered. Hormone tests are not required in women with heavy but regular menstrual loss and testing for clotting disorders is only recommended for women with a lifelong history of HMB.1

History taking should be focused on the impact of the problem, and to determine if any more investigations are required, including a pregnancy test, screening for sexually transmitted infections (STIs), and a cervical cytology test. Other investigations for HMB are dictated by the history:

  • symptoms of pelvic pressure, increase in urinary frequency, or pelvic mass require an examination; the recommended investigation for structural pathology, such as large fibroids, is a pelvic and transvaginal ultrasound scan1
  • if the history is more suggestive of histological pathology—persistent intermenstrual bleeding (IMB), endometrial risk factors (see Box 2),5 or failed previous treatment—then hysteroscopy is the first-line investigation recommended by NICE1
  • if, as is the case in most women, there are no abnormal features other than increased menstrual loss, then treatment can begin without the need for investigations or examination provided that the cytology history is normal and within the requirements of the cervical screening programme (see Box 3).

Box 2: Risk factors for endometrial hyperplasia5

  • Obesity
  • Unopposed oestrogen from anovulatory cycles in polycystic ovary syndrome and perimenopause
  • Drug-induced endometrial stimulation, e.g. use of systemic oestrogen-only replacement therapy or long-term tamoxifen)
  • Oestrogen-secreting ovarian tumours, e.g. granulosa cell tumours.

Initial medications prescribed at first contact are those recommended by NG88,1 and are dependent on the woman’s imminent fertility requirements or any contraindications. The provision of immediate relief by prescribing tranexamic acid 1–1.5 g three-times daily for 4 days is recommended while any further investigations are done, or while the woman has time to consider her longer-term management options.

An acute episode of HMB may be due to anovulation with a history of menstrual delay and then a prolonged and heavy bleed. A 10-day course of medroxyprogesterone acetate (MPA) 10 mg twice daily may be all that is required to stop the current bleed and the woman may then resume her normal ovulatory cycles.

The longer-term management decision can be made at a follow-up consultation after the woman has had the opportunity to seek appropriate information online, such as the NICE-endorsed shared decision-making aid for HMB, Heavy periods: what are my options?6

The levonorgestrel-releasing intrauterine system (IUS) remains the recommended treatment of choice for management of HMB,1 achieving an 80–90% reduction in menstrual loss, with low treatment cost and low risk of complications.6 This and other options are outlined in Box 3 and include endometrial ablation. Women with fibroids of 3 cm or more in diameter should be considered for referral to specialist care to undertake additional investigations and discuss treatment options—provide short term treatment while waiting for specialist care.1

Note: Not all of the treatments discussed in this article currently (December 2020) have UK marketing authorisation. The prescriber should follow relevant professional guidance, taking full responsibility for all clinical decisions. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices7 for further information.

Box 3: Treatment options for heavy menstrual bleeding1

Hormonal

  • Levonorgestrel-releasing intrauterine system
  • Combined hormonal contraception after exclusion of contraindications
  • Medroxyprogesterone acetate:
    • long cycle (21 days followed by a 7-day break) or
    • continuous treatment.

Non-hormonal

  • Tranexamic acid
  • Any non-steroidal anti-inflammatory drug.

Surgical—non-reversible

  • Endometrial ablation.

Endometrial ablation is a choice for women who want a treatment that is non-reversible and is only appropriate for those who have completed their family. Many techniques are suitable for the outpatient setting, using local anaesthesia, so reducing the requirement for general anaesthesia and inpatient recovery time. 

Hysterectomy for management of HMB has been included in the list of inappropriate interventions produced by the Evidence-based interventions programme,8 and is not indicated as a first-line treatment.

Non-menstrual bleeding in women of reproductive age

Vaginal bleeding that is not related to menstruation is also a common concern for women and healthcare professionals. The essential information to elicit from the woman’s history is whether it is PCB or true IMB (see Box 4), as the requirements for examination and investigation may differ.

As ever it is important to exclude pregnancy, STIs, or cervical pathology and to ensure exogenous hormone use is not the cause of the menstrual irregularity. Once these are considered and excluded, then the course of action can be determined.

Box 4: History for non-menstrual bleeding9

  • What is the duration, frequency, and amount of bleeding?
  • What is the relationship of the non-menstrual bleeding to normal menstruation and sexual intercourse?
  • What is the woman’s normal bleeding pattern and date of the last normal menstrual period?
  • Has she had any change in vaginal discharge?
  • Is she at risk of sexually transmitted infections?
  • Could she be pregnant?
  • Is she up to date with her cervical screening?
  • Is she using any hormonal contraception?
  • Does she have a history suggestive of a clotting disorder?
  • Is she taking anticoagulants?
  • Is there any trauma to the genital tract?

Intermenstrual bleeding that happens mid-cycle, with or without pain, may be due to normal physiological hormonal changes. In women with no risk factors, reassurance may be all that is required; however, manipulation by hormonal contraception is an option. 

Erratic bleeding is common for women when starting any hormonal method of contraception and often subsides with no further intervention, if pregnancy and STIs are excluded. Ongoing or recurrent bleeding when the woman is established on hormonal contraception requires assessment.

Unscheduled bleeding caused by combined hormonal contraception may result from non-compliance or concurrent use of enzyme-inducing medication, including St John’s wort. The recommended management options include altering the progestogen component (switching to a different progestogen preparation) or increasing the dose of ethinyl-oestradiol in the preparation (switching to a preparation with higher ethinyl-oestradiol content). Unpredictable bleeding is common with progestogen-only contraceptive methods and appropriate warning should be included in counselling when starting the method. For problematic bleeding, the addition of a combined hormonal contraceptive, if not contraindicated (see the Faculty of Sexual and Reproductive Healthcare [FSRH] UK medical eligibility criteria),10 or additional (or doubling) desogestrel pill, may be enough. Further information can be found in the FSRH guidance on problematic bleeding with hormonal contraception.11

Sexually transmitted infections such as chlamydia can cause cervicitis or endometritis, which may cause IMB or PCB with no other symptoms, or there may be dyspareunia or pelvic pain suggestive of pelvic inflammatory disease (PID). Examination of any possible case of PID is required as early treatment is indicated to prevent the long-term sequelae of chronic pelvic pain and subfertility.

Other causes of IMB may include endometrial pathology, such as an endometrial polyp, submucosal fibroid, or endometrial hyperplasia and malignancy. In women aged 40 years or over with persistent IMB for 3 consecutive months, referral for hysteroscopy for endometrial assessment is the investigation of choice.1,4 Endometrial cancers are rare in premenopausal women, but an individualised risk assessment determines which women require hysteroscopic investigation (see Box 2).

Postcoital bleeding is more likely to arise from the lower genital tract and requires examination of the vulva, vagina, or cervix. A vulvo-vaginal swab may exclude chlamydia infection as the cause of cervicitis. Women with an in-date negative cervical screening test are unlikely to have significant cervical pathology but referral for a colposcopy is recommended if:2

  • the appearance of the cervix suggests a malignancy
  • the woman is aged 35 years or under with abnormal, absent, or overdue cervical screening
  • the woman is aged over 35 years, regardless of cervical screening history.

Postmenopausal bleeding

Postmenopausal bleeding, defined as unexplained vaginal bleeding more than 12 months after the last menstrual period,12 is regarded as a red-flag symptom.2 It requires a fast-track referral, as endometrial cancer will be the cause in 5–10% of cases.13 To ensure the woman is seen in the correct clinic first time, it is essential to check the cervical screening is up to date and perform speculum examination if it is not.

The recommendation in NICE Guideline 12 on Suspected cancer: recognition and referral12 is to:

  • refer women using a suspected cancer pathway referral for endometrial cancer if they are aged 55 and over with PMB
  • consider a suspected cancer pathway referral for endometrial cancer in women aged under 55 with PMB.

Unscheduled bleeding on HRT

Unscheduled bleeding on HRT is common in the first 6 months of use or when changing from a cyclical to a continuous combined preparation.

As usual, the clinical history is important to ensure:

  • treatment compliance
  • appropriate choice of HRT
  • exclusion of pregnancy, STIs, or cervical problems.

Examination may be appropriate if the last cervical smear is overdue or the unscheduled bleeding was ongoing before starting HRT. For most women, modifying the progestogen component of the HRT will control the unscheduled bleeding (see Box 5).14

Women with unscheduled bleeding on HRT can be reassured that the risk of endometrial cancer when using a continuous combined preparation is lower than when using no HRT,15 especially if they had been experiencing no irregular bleeding before starting a combined preparation. However, referral may need to be considered if the unscheduled bleeding continues beyond 6 months despite modifying the progestogen component of the HRT.3,14

Box 5: Modifying HRT to control unscheduled bleeding14

IUS and HRT

  • Keep IUS in situ and add in progestin, MP, MPA, or NET or swap to a cyclical progestogen regimen.

Cyclical HRT

  • Increase progestin:
    • dose (MPA 20 mg or MP 300 mg for 12–14 days for 28-day cycle), or
    • duration (e.g. MPA 20 mg for 21 days of 28-day cycle), or
  • Change progestin type (e.g. MPA has good endometrial affinity and may provide the best bleed control).

Continuous combined HRT

  • Increase progestin dose (e.g 100 mg MP to 200 mg daily, 5 mg MPA to 10 mg)
  • Swap progestin (to MPA or NET).

HRT=hormone replacement therapy; IUS=intrauterine system; MP=micronised progesterone (body identical); MPA=medroxyprogesterone acetate; NET=norethisterone

Primary Care Women’s Health Forum. How to manage HRT provision without face to face consultations during COVID-19 healthcare restrictions.  Arlesey: PCWHF, 2020. Available at: pcwhf.co.uk/wp-content/uploads/2020/05/PCWHF-Menopause-Management-remote-consultation-tool_V4.pdf

Reproduced with permission

Summary

Since the start of the COVID-19 pandemic and the need for changes in access to healthcare to reduce infection transmission, remote consulting has become the normal first point of contact for primary care. Primary care clinicians have rapidly learned to triage and arrange face-to-face consultation or remote management.

The joint RCOG, BSGE, and BGCS guidance on the management of AUB in the COVID-19 pandemic has provided an excellent base from which to reconsider how best to manage and support women during this time.2 All of this has provided opportunities for learning for the future, offering women better access to advice when appropriate and without requiring unnecessary time off work or away from their busy lives.

The Royal College of General Practitioners’ Menstrual wellbeing toolkit offers further useful information on the management of menstrual problems, including top tips, e-learning, and podcasts (www.rcgp.org.uk/menstrualwellbeingtoolkit).16

Dr Anne Connolly

GP, Bradford

GPwSI in Gynaecology

Chair of the Primary Care Women’s Health Forum

RCGP Clinical Champion in Women’s Health

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Review local care pathways for the management of AUB, update these as needed, and alert primary care to the recommendations in this article during the pandemic
  • Emphasise that good remote assessment, and taking a careful history, can reduce (but not replace) the need for face-to-face assessments during the pandemic
  • Ensure that face-to-face assessments for examination are available promptly for people with worrying or red-flag symptoms
  • Consider publishing on a local website resources that patients can refer to directly for advice and guidance on when to consult about AUB
  • Check that any e-consultation platforms used in the pandemic mirror the guidance you have agreed in your local care pathway
  • Continue provision of IUS fitting services in the pandemic for the treatment of menorrhagia.

STP=sustainability and transformation partnership; ICS=integrated care system; AUB=abnormal uterine bleeding; IUS=intrauterine system

Guidelines Learningcpd logo

After reading this article, ‘Test and reflect’ on your updated knowledge with our patient scenarios. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

References

  1. NICE. Heavy menstrual bleeding: assessment and management. NICE Guideline 88. NICE, 2018 (updated 2020). Available at: www.nice.org.uk/ng88
  2. Royal College of Obstetricians and Gynaecologists, British Society for Gynaecological Endoscopy, British Gynaecological Cancer Society. Joint RCOG, BSGE and BGCS guidance for the management of abnormal uterine bleeding in the evolving coronavirus (COVID-19) pandemic. London: RCOG, 2020. Available at: www.rcog.org.uk/globalassets/documents/guidelines/2020-05-21-joint-rcog-bsge-bgcs-guidance-for-management-of-abnormal-uterine-bleeding-aub-in-the-evolving-coronavirus-covid-19-pandemic-updated-final-180520.pdf
  3. Primary Care Women’s Health Forum. How to manage women presenting with abnormal uterine bleeding in primary care without face to face contact. Arlesey: PCWHF, 2020. Available at: pcwhf.co.uk/wp-content/uploads/2020/04/PWCHF-HMB-without-face-to-face-contact.pdf
  4. Pennant M, Mehta R, Moody P et al. Premenopausal abnormal uterine bleeding and risk of endometrial cancer. BJOG 2017; 124 (3): 404–411.
  5. Royal College of Obstetricians and Gynaecologists. Management of endometrial hyperplasia. Green-top Guideline No. 67. London: RCOG, 2016. Available at: www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg_67_endometrial_hyperplasia.pdf
  6. Kumar G. Shared decision making aid for heavy menstrual bleeding. Wrexham: Betsi Cadwaladr University Health Board, 2018 (updated 2020). Available at: www.wisdom.wales.nhs.uk/sitesplus/documents/1183/HMB_Shared_Decision_Making_Aid_Updated_version_Mar-2020.pdf
  7. General Medical Council. Good practice in prescribing and managing medicines and devices. London: GMC, 2013. Available at: www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices (accessed 6 December 2020).
  8. NHS England. Evidence-based interventions: guidance for CCGs. NHS England in partnership with NHS Clinical Commissioners, the Academy of Medical Royal Colleges, NHS Improvement, and NICE. Redditch: NHS England, 2018 (updated 2019). Available at: www.england.nhs.uk/wp-content/uploads/2018/11/ebi-statutory-guidance-v2.pdf
  9. Connolly A, Jones S. Nonmenstrual bleeding in women under 40 years of age. Obstet Gynaecol 2004; 6: 153–158.
  10. The Faculty of Sexual and Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. London: FSRH, 2016 (updated 2019). Available at: www.fsrh.org/standards-and-guidance/documents/ukmec-2016/ (accessed 6 December 2020).
  11. The Faculty of Sexual and Reproductive Healthcare. Problematic bleeding with hormonal contraception. London: FSRH, 2015. Available at: www.fsrh.org/standards-and-guidance/documents/ceuguidanceproblematicbleedinghormonalcontraception/ (accessed 6 December 2020).
  12. NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015 (updated 2020). Available at: www.nice.org.uk/ng12
  13. Gredmark T, Kvint S, Havel G, Mattsson L-Å. Histopathological findings in women with postmenopausal bleeding. BJOG 1995; 102 (2): 133–136.
  14. Primary Care Women’s Health Forum. How to manage HRT provision without face to face consultations during COVID-19 healthcare restrictions.  Arlesey: PCWHF, 2020. Available at: pcwhf.co.uk/wp-content/uploads/2020/05/PCWHF-Menopause-Management-remote-consultation-tool_V4.pdf
  15. The Writing Group for the PEPI Trial. Effects of hormone replacement therapy on endometrial histology in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) trial. JAMA 1996; 275 (5): 370–375.
  16. Royal College of General Practitioners. Menstrual wellbeing toolkit. Available at: www.rcgp.org.uk/menstrualwellbeingtoolkit (accessed 6 December 2020).