The scenarios are fictitious but similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could be also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid. 

Icon used to indicate Guidelines in Practice test and reflect content

The following case studies, written by Dr Anne Connolly, relate to her expert article, Abnormal uterine bleeding: management in COVID-19 and beyond. In her article, Dr Connolly discusses various types of abnormal uterine bleeding, underlying causes, appropriate interventions, and when it may be necessary to refer.

Case 1: Maria, 38 years old

Context

Maria is a teacher at the local primary school. She telephones for an appointment to discuss her periods, which have been getting heavier over the past 6 months and have caused her to have a few ‘accidents’ at work. Last night she ‘flooded’ and had to change the bedding at 04.00. She felt dizzy when she got up this morning and has already changed her pad 10 times today. Her husband is concerned because she always seems tired and he encouraged her to telephone for an appointment.

Questions for reflection

  1. What further information is helpful?
  2. What investigations are you considering?
  3. What management would you recommend?

Reveal how to manage this patient

Heavy menstrual bleeding (HMB) is a common complaint to primary care with an estimated 1 in 20 women experiencing the problem during their reproductive lifetime.1 NICE Guideline 88 on HMB1 encourages clinicians to appreciate the physical, social, and psychological impact this has for a woman and recommends the process to follow for diagnosis and management.

Taking a careful history and consulting the medical record enable an individual risk assessment that dictates if examination and investigations are required. Exclusion of a pregnancy or sexually transmitted infection is required when dealing with any menstrual concern, ensuring cervical cytology is up to date, and then considering if there could be a histological or structural (fibroids) cause.

In the case of Maria, this problem has been recent in onset and she is having regular, heavy bleeds with no non-menstrual bleeding. In the medical record there is enough information to exclude any risk factors for endometrial hyperplasia, for example obesity, diabetes, polycystic ovary syndrome, or tamoxifen treatment, and an up-to-date negative cervical cytology result. A few simple questions exclude a large fibroid in the uterus (pelvic pressure, and increase in urinary frequency), which reduces the need for examination.

To reduce the anxiety that Maria has about managing her career and home life with the risk of ‘flooding accidents’, it is important to offer short-term treatment at this first contact while she has time to consider longer-term management. Prescribing tranexamic acid 1–1.5 g to be taken three-times daily while bleeding will reduce the menstrual loss and allow time to review the treatment options using the NICE-endorsed shared decision-making aid for HMB, Heavy periods: what are my options?2 If pain is a concern, then the addition of any non-steroidal anti-inflammatory drug, having excluded contraindications, may help further reduce blood loss and provide the analgesia required.

NICE recommends that all women presenting with HMB require a full blood count test to exclude the insidious onset of anaemia that persistent excessive bleeding causes.1 In the case of Maria, the pattern of menstruation continues to be regular, so no further blood tests are required. She also has no endometrial risk factors or symptoms of a pelvic mass, therefore, examination or further investigations are not required at this initial stage but may be considered later if the treatment response if inadequate.

First-line medical treatment options can be divided into the two categories of hormonal and non-hormonal therapies with the levonorgestrel-releasing intrauterine system remaining the recommended option, having low risk, good treatment outcomes, and acceptability.1

Endometrial ablation is the first-line surgical intervention recommendation with newer techniques in the outpatient setting reducing the requirement for inpatient stay. This procedure is irreversible and only appropriate where fertility is no longer required.

References

  1. NICE. Heavy menstrual bleeding: assessment and management. NICE Guideline 88. NICE, 2018 (updated 2020). Available at: www.nice.org.uk/ng88
  2. 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

Case 2: Gemma, 46 years old

Context

Gemma works in the local supermarket. She telephones for an appointment because her periods have been getting heavier and over the past 6 months, she has had a few ‘accidents’ at work. She is well-known to the practice because of her regular attendance at the diabetic clinic and dietitian.

Questions for reflection

  1. What further information is helpful?
  2. What investigations are you considering?
  3. What management would you recommend?

Reveal how to manage this patient

The case of Gemma is more concerning than Maria’s and investigations are required before determining her future management options. Obesity and diabetes are both risk factors for the development of endometrial hyperplasia and cancer, with NICE Guideline (NG) 88 on heavy menstrual bleeding (HMB) recommending investigation before more definitive treatment.1

A menstrual history determines if Gemma is experiencing any non-menstrual bleeding or has any other factors that might affect the immediate management of her problem, including risk of pregnancy or sexually transmitted infection. If her cervical screening is overdue, then examination and cytology are required with colposcopy referral if there are abnormal appearances suggesting that this could be the cause of her problem.

NG88 recommends a full blood count test and treatment with tranexamic acid should be offered to improve her symptoms while waiting for further investigations and management.1 The guideline also recommends hysteroscopy as the investigation of choice in this case to allow visualisation of the endometrium and a direct biopsy of any pathology.

Treatment is dependent on the histological findings, including resection of endometrial pathology (polyp or submucosal fibroid). NG88 recommends the levonorgestrel-releasing intrauterine system (LNG-IUS) as the first-line treatment for HMB1 and the Royal College of Obstetricians and Gynaecologists and British Society for Gynaecological Endoscopy joint guideline2 recommends LNG-IUS for the prevention and reversal of endometrial hyperplasia with no atypia. Cases found to have endometrial hyperplasia with atypia or endometrial malignancy require discussion at the multidisciplinary team meeting for a future management plan.

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 and British Society for Gynaecological Endoscopy. Endometrial hyperplasia, management of (green-top guideline no. 67). London: RCOG, 2016 (updated 2017). Available at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg67/

Case 3: Ruth, 49 years old

Context

Ruth is well-known to the surgery because of her asthma. Her menopausal symptoms have improved significantly since she started hormone replacement therapy (HRT) 4 months ago. She is functioning better at work now that her sleep pattern has improved and she is experiencing no embarrassing flushing episodes during work meetings. She requests a consultation because she has been getting some irregular bleeding since starting HRT.

Questions for reflection

  1. What further information is helpful?
  2. What investigations are you considering?
  3. What management would you recommend?

Reveal how to manage this patient

Irregular bleeding when starting to use HRT is common but there are a few basic points to clarify before reassuring Ruth.

  • Is she compliant with the HRT?
  • Was her menstrual cycle normal before starting the HRT?
  • Was she already postmenopausal and amenorrhoeic for more than 1 year?
  • Is she using a sequential or a continuous combined HRT preparation?
  • If she is using a sequential combined HRT is there a pattern to when the irregular bleeding is happening?
  • Is her cervical screening up to date and was the last result normal?
  • Is she taking any other medication, including hormonal contraception?

If her menstrual cycle was normal and cervical screening was up to date before starting the HRT, and ensuring the product used is a combination of oestrogen and progestogen, she can be reassured that for women using combined HRT the risk of endometrial cancer is lower than for women not using HRT.

If the irregular bleeding is problematic and ongoing then an appropriate first step would be to consider increasing the progestogen dose or extending the number of days of use of progestogen, if using a sequential preparation. If using a continuous combined preparation, a trial of returning to a sequential combined product might be appropriate as she may be continuing to have some ovulatory bleeding and regulating the cycle might be less concerning for her. Alternatively, addition of a desogestrel pill may also help in the scenario of ongoing irregular bleeding when starting a continuous combined preparation.

Concerning features requiring referral for hysteroscopy for endometrial investigation include onset after a time of amenorrhoea, persistent irregular bleeding in spite of using one of the above recommendations, ongoing bleeding after discontinuation of HRT, or persistent bleeding in a woman who was given HRT when already having an erratic menstrual cycle.

Reference

  1. 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

Case 4: Sheila, 62 years old

Context

Sheila retired from her job as a librarian 2 years ago. She telephones the practice for an appointment. She really does not want to make a fuss but says she has had some vaginal bleeding—‘spotting’—for a few days. She had a similar problem last week but it only lasted for a day and by the time she decided to telephone for an appointment it had stopped.

Questions for reflection

  1. What further information is helpful?
  2. What investigations are you considering?

Reveal how to manage this patient

Postmenopausal bleeding (PMB) is defined as bleeding more than 12 months after the last menstrual period in the absence of hormonal use.1 This complaint is considered to warrant a 2-week referral according to NICE Guideline 12 on Suspected cancer: recognition and referral.1

Before referral, it is essential to confirm the bleeding is vaginal in origin to ensure the referral is made to the correct specialty first time. If Sheila’s latest cervical screening is within the time recommendations for the cervical screening programme, a referral can be made remotely without examination. However, if her cervical screening is overdue, or her last result was abnormal, cervical examination is essential before referral to reduce delay in the case where colposcopy would be a more appropriate investigation.

Fast-track referrals for PMB should be seen in a one-stop PMB clinic where an ultrasound scan will be the initial investigation. The ultrasound scan enables assessment of the ovaries to exclude an ovarian cause for PMB and also an estimation of the endometrial thickness. As in most cases PMB is caused by atrophy, a thin endometrium reduces the need for hysteroscopy. Each local service determines their own cut-off measurement with most agreeing that women with an endometrial thickness of 4 mm or more require endometrial assessment.

Reference

  1. NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015 (updated 2020). Available at: www.nice.org.uk/ng12