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Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G

Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G. Aims. To review the guidelines on the management of abnormal vaginal bleeding in young women To concentrate on the investigation/ management to be carried out before referral to colposcopy clinic. Why is it important?.

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Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G

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  1. Unscheduled bleeding in young women Dr Kathryn Hill GPST2 in O+G

  2. Aims • To review the guidelines on the management of abnormal vaginal bleeding in young women • To concentrate on the investigation/ management to be carried out before referral to colposcopy clinic

  3. Why is it important? • 1/600 women aged 20-24y reported PCB per year • 0.5-1% women aged 20-24y present with IMB/ year • Estimated 7500 – 15000 women will present each year

  4. DoH Clinical Practice Guidelines • Women aged 20-24y • Abnormal vaginal bleeding relatively common • To prevent delay of referral to colposcopy in rare cases of cancer

  5. Management - PCB • History • Speculum examination • If clinically suspicious 2ww • If local problem treat or refer • If normal for swabs • Refer if bleeding persists 6-8 weeks • Women over 35y PCB >4w refer colposcopy (Scottish Guidelines)

  6. Management - IMB • History • If suspected OCP problem – modify contraception • If bleeding persists (6-8 weeks) – speculum

  7. FSRH - management of unscheduled bleeding on hormonal contraception • Frequent / prolonged / irregular / spotting • Many due to method of hormonal contraception • Endometrial and cervical cancer rare • Early vs late symptoms • May not need examination

  8. FSRH - management of unscheduled bleeding on hormonal contraception • COCP/ Patch/ Ring: Upto 20% have irregular bleeding in 1st 3m Usually settles Use lowest oestrogen dose for cycle control May need to increase from 20mcg to 30-35mcg No evidence tricycling settles bleeding • Progesterone only Bleeding pattern on one method does not predict bleeding patterns with another method

  9. FSRH - management of unscheduled bleeding on hormonal contraception • POP: Early - 30% change in bleeding and 10% irregular Later – 50% regular bleed and 30-40% irregular No evidence changing type of pill will help No evidence that 2 pills per day will help • Injectable: 35% amenorrhoeic at 3m and 70% at 1y No evidence reducing interval improves bleeding Mefenamic acid 500mg bd 5d reduced length of bleeding episode. No long term effect.

  10. FSRH - management of unscheduled bleeding on hormonal contraception • Implant: At 6m 30% infrequent and 10-20% prolonged bleeding Doxycycline may help but limited evidence • IUS: Irregular, light or heavy in 1st 6m 65% have amenorrhoea or reduced bleeding at 1y No evidence for treatment options • Injectable / Implant / IUS:COC upto 3m (usual use or continuous) recommended if not contraindicated

  11. History Consider examination Consider investigation for infections Modify hormonal contraception Refer if persistant bleeding for 6-8 week Summary

  12. References • Clinical practice guidance for the assessment of young women aged 20-24 with abnormal vaginal bleeding. DoH Mar2010. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113553.pdf • Management of unscheduled bleeding in women using hormonal contraception. FSRH May2009. http://www.rcog.org.uk/files/rcog-corp/UnscheduledBleeding23092009.pdf • Persistant PCB. RCOG Query bank. http://www.rcog.org.uk/womens-health/clinical-guidance/persistent-post-coital-bleeding-query-bank

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