Medical maps: gynaecological bleeding

Fibroid histopathology.

Abnormal vaginal bleeding can be acute or chronic. Acute bleeds are often related to pregnancy (ectopics, miscarriage) and I will discuss these pathologies in obstetrics.

Here we will focus on chronic gynaecological bleeding issues. We can divide this into:

  • Abnormal bleeding during reproductive ages – called ‘abnormal uterine bleeding’ (AUB) – the most important symptoms of which are:
    • Heavy menstrual bleeding (HMB)
    • Intermenstrual bleeding (IMB)
    • Infrequent bleeding, where the interval between menstruation (i) is longer than expected
      • Oligomenorrhoea (35 days < i < 6 months)
      • Amenorrhoea (6 months < i)
    • Postcoital bleeding (PCB) – think cervical pathology here
  • Bleeding outside of reproductive ages, which is always abnormal:
    • Precocious puberty and premature menarche
    • Non-menstrual vaginal bleeding in children
    • Post-menopausal bleeding

Abnormal bleeding during reproductive ages (AUB)

The best way to think about AUB is using FIGO’s classification (original paper here with 2018 update here), called PALM|COEIN.

  • PALM = structural causes that can be diagnosed with imaging and/or histopathology
    • Polyps, adenomyosis, leiomyomas (fibroids) and malignancy
      • L: subclassified into submucosal fibroids (which could cause menstrual problems) and ‘other’ (intramural, subserosal – unlikely to cause menstrual problems)
      • M: important ones are cervical, uterine (endometrial or leiomyosarcoma)  and ovarian
  • COEIN = non-structural causes – a diagnosis can be implied or reached through history, clinical examination and laboratory tests
    • Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not specified (for our purposes: idiopathic)
      • O: caused by PCOS and other endocrine issues (PRLoma, hypothyroid, eating disorders)
      • E: an important group of disorders that fit here are infections of the endometrium (endometritis)
        • FIGO mentions ‘disorders of endometrial homeostasis’ in the ‘E’ category, which are probably also a big cause of ‘N’ (i.e. idiopathic causes) but not enough is known about the pathophysiology to say more at this stage… I wouldn’t worry about this too much
      • I: think both of anticoagulants (warfarin, heparin, NOACs) and hormonal medications that can cause irregular bleeding
        • When unscheduled bleeding happens to a patient on hormonal medications, it is termed ‘breakthrough bleeding’ (BTB) – progesterone medications are particularly associated BTB

The FIGO paper recommends that when a lady presents with any type of AUB, you make a little matrix, like the one shown below.

Screenshot 2019-06-20 at 11.29.36.png

AUB causes matrix

For exam purposes, I would say:

  • Always think – could this person be pregnant?
    • Pregnancy (and early pregnancy issues like ectopics, miscarriages) can present as menstrual irregularities so it is important to ask this question
    • PPALM|COEIN might work for you…
  • HMB – the most diverse, consider ALL of PALM|COEIN
  • IMB – P (e.g. when they tort), M, C, E (infections – endometritis), I
  • Infrequent – all about O and I
    • O: menopause, pregnancy, endocrinopathies (PCOS, PRLoma, adrenal hyperplasia, adrenal tumours, anorexia), premature ovarian failure (defined as amenorrhoea for 12 months, under the age of 40)
    • I: hormonal medications (oestrogens, progesterones, androgens) but other medications can interfere with the hypothalamic-pituitary-ovarian axis (e.g. tricyclic antidepressants)
  • PCB – the PALM|COEIN system wasn’t really designed for this symptom, but P and M (cervical cancer) definitely apply
    • You should also think about cervical ectropion (which can be caused by I – oral contraceptive usage), cervicitis and trauma

Bleeding outside of reproductive ages

Precocious puberty and premature menarche – The first menstruation occurring too early (<8 years) is called premature menarche, and we can lump this together with precocious puberty. I will discuss this in more detail in paediatrics.

Non-menstrual vaginal bleeding in children – a symptom to be aware of, because it raises concerns for safeguarding (see here).

Post-menopausal bleeding – classic exam material, because this is a red flag symptom for endometrial cancer. It can also be caused by vaginal atrophy – where the vaginal skin becomes thinner due to reduced oestrogen post-menopause.

Summary

Here goes – let’s outline the gynaecological bleeding framework:

Framework for chronic gynaecological bleeding issues – this will fit into the overall gynaecology framework. Click to zoom.

 

 

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