Abnormal Bleeding (Pre-Menopausal)

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1 Background Information / Scope of Pathway

These pathways were developed to guide clinicians when managing abnormal bleeding in pre-menopausal patients.
The pathways are not provider specific and so the guidance and forms apply to all providers.

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2 Information Resources for Patients and Carers

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3 Development and Updates to this Pathway

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4 Referral Forms

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7 Heavy menstrual bleeding with of IMB/PCB

Post Coital Bleeding (PCB)
PCB is spotting or bleeding that occurs after intercourse. It is unrelated to menses.

Intermenstrual Bleeding (IMB)
IMB is vaginal bleeding (other than post coital) at any time during the menstrual cycle other than during normal menstruation.

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10 Discuss variation that can occur in periods

Single episode is not considered abnormal

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12 Pharmaceutical Treatment

If patient has heavy menstrual bleeding and feel their periods are not within normal variation range offer pharmaceutical treatment (order of treatment will depend on a number of variables – clinical picture, patient suitability and wishes and acceptability of treatment. Treatment should be guided by clinical judgement and patient suitability);
Consider Mirena if clinically appropriate
Tranexamic Acid is useful but just as control for heavy periods not to regulate the cycle (could be used in conjunction with any NSAID )
Combined Oral Contraception
Progestogen Only PillLNG IUS (Mirena – If practice doesn’t fit Mirenas then refer to community or GPSI)
Cyclical Norethisterone prescribed from day5-26 5mg tds can be used to regulate the cycle and to control heavy bleeding but is used less now as side effects are greater than with mirena and POP.

If patient trying to conceive refer to infertility unless suspect cancer

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13 Examination

Vulva, Vagina and Cervix visualised, bimanual performed.
If suspect cancer refer as appropriate
If cervical polyp found don’t assume polyp is the cause of the bleeding. Refer to asymptomatic polyp pathway
Ectropion is a normal finding

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14 Consider STI Screen and Smear

Patients aged <25 years with no smear, visualise cervix. If normal then reassure patient this is unlikely to represent pathology.

Bleeding when taking a smear is not a reason for referral
Ectropion is a normal finding. Smear not to be taken when not necessary

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21 If unable to perform examination or abnormality found and ultrasound may be required

If there is a concern of malignancy refer to the 2 week pathway

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23 Alternative Pharmaceutical Treatment

If, after 6 months, the pharmaceutical treatment was not successful then offer another pharmaceutical treatment;
Mirena - If practice doesn’t fit Mirenas then refer to community or GPSI
Tranexamic Acid,
Combined Oral Contraception
Progestogen Only Pill
Or add a second drug
Norethisterone/medroxyprogesterone prescribed from day 5-26 5mg tds
(/ Provera 10mg tds or Depo-Provera)

A Mirena does not require removal.

A Mirena should be offered as one of the pharmaceutical treatments offered as hysteroscopy won’t be performed if treatment fails unless one of the treatments was the fitting of a Mirena

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24 Treatment

If fibroids are detected pharmaceutical treatment may still be effective depending on patient’s age and fertility wishes.
If patient trying to conceive refer to infertility unless suspect cancer

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31 Council patient re next steps

If family complete consider surgery