Irregular Vaginal Bleeding

Definition | Aetiology | Risk Factors | Clinical Assessment | Investigations | Management | When to Refer | References

Definition

Irregular vaginal bleeding refers to any abnormal bleeding from the uterus that deviates from the normal menstrual cycle. It can manifest as bleeding between periods (intermenstrual bleeding), heavy menstrual bleeding (menorrhagia), or postmenopausal bleeding.

Aetiology

The causes of irregular vaginal bleeding are diverse and can range from benign to serious. Common causes include:

• Hormonal Imbalances: Common in perimenopausal women or those with polycystic ovary syndrome (PCOS).
• Uterine Fibroids: Benign growths in the uterus that can cause heavy and irregular bleeding.
• Endometrial Polyps: Small growths in the lining of the uterus that may cause intermenstrual bleeding.
• Endometriosis: Presence of endometrial tissue outside the uterus, leading to painful and irregular periods.
• Contraceptive Use: Irregular bleeding can occur with the use of hormonal contraceptives, especially in the first few months.
• Infection: Pelvic inflammatory disease (PID) and other infections can cause irregular bleeding.
• Malignancy: Cervical, endometrial, or ovarian cancer, particularly in postmenopausal women.
• Coagulation Disorders: Conditions like Von Willebrand disease can cause abnormal bleeding.

Risk Factors

• Age (adolescence, perimenopause, postmenopause).
• Obesity.
• Polycystic ovary syndrome (PCOS).
• History of irregular menstrual cycles.
• Use of hormone replacement therapy (HRT).
• Use of intrauterine devices (IUDs).
• Smoking.

Clinical Assessment

Initial assessment by a Physician Associate should include a thorough history and physical examination:

• History: Document the pattern of bleeding, associated symptoms (e.g., pain, discharge), contraceptive use, and any risk factors for malignancy.
• Examination: Pelvic examination to assess for masses, tenderness, or signs of infection. A speculum examination may be needed to visualise the cervix.
• Routine Screening: Ensure cervical screening (smear test) is up to date.

Investigations

Appropriate investigations in primary care include:

• Full Blood Count (FBC): To check for anaemia.
• Thyroid Function Tests: To rule out thyroid disorders as a cause of abnormal bleeding.
• Serum Ferritin: To assess iron stores in cases of heavy bleeding.
• Pelvic Ultrasound: First-line imaging to assess for fibroids, polyps, or other structural abnormalities.
• Endometrial Biopsy: Consider in women over 45 or in younger women with risk factors for endometrial hyperplasia or cancer.

Management

Management of irregular vaginal bleeding depends on the underlying cause and the patient's circumstances:

Primary Care Management

• Hormonal Treatment:
  • Combined Oral Contraceptive Pill (COCP): Useful for regulating menstrual cycles in women without contraindications.
  • Progesterone-only Pill or Injectable: Option for women who cannot take oestrogen.
  • Mirena Coil (Levonorgestrel IUD): Effective for reducing heavy menstrual bleeding and providing contraception.
• Non-Hormonal Treatment:
  • Tranexamic Acid: An antifibrinolytic used to reduce heavy menstrual bleeding.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Such as ibuprofen, to reduce menstrual blood loss and alleviate pain.
  • Iron Supplements: If anaemia is present.
• Management of Infections:
  • Antibiotics: Appropriate antibiotics based on culture results or empirical treatment for pelvic inflammatory disease.

Secondary Care Management

• Referral to Gynaecology: Indicated if there is suspicion of malignancy, persistent symptoms despite primary care treatment, or if advanced imaging or surgery is required.
• Surgical Options:
  • Hysteroscopy: To diagnose and potentially treat intrauterine pathologies such as polyps or submucosal fibroids.
  • Endometrial Ablation: An option for women with heavy menstrual bleeding who have completed their family.
  • Hysterectomy: May be considered for severe cases not responding to other treatments, especially in women with significant fibroids or refractory symptoms.

When to Refer

Referral to secondary care (Gynaecology) should be considered in the following scenarios:

• Failure of Medical Management: If there is no improvement after a trial of medical therapy in primary care.
• Suspected Malignancy: If any concerning features are present (e.g., postmenopausal bleeding, abnormal pelvic examination).
• Structural Abnormalities: Such as large fibroids or suspected endometrial pathology that requires surgical management.
• Severe Anaemia: Due to heavy menstrual bleeding that cannot be managed in primary care.
• Patient Preference: If the patient prefers surgical intervention after discussing options.

References

1. NHS (2024) Irregular Periods. Available at: https://www.nhs.uk/conditions/irregular-periods/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Heavy Menstrual Bleeding: Assessment and Management. Available at: https://www.nice.org.uk/guidance/ng88 (Accessed: 26 August 2024).
3. Royal College of Obstetricians and Gynaecologists (2024) Management of Acute and Chronic Pelvic Pain. Available at: https://www.rcog.org.uk/guidance/care-pathways/pelvic-pain/ (Accessed: 26 August 2024).
4. British Medical Journal (2024) Management of Menstrual Disorders in Primary Care. Available at: https://www.bmj.com/content/350/bmj.h682 (Accessed: 26 August 2024).

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