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IMB - Guidelines For Referral




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IMB - Guidelines For Referral

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IMB - Guidelines For Referral
Table of Contents
  • 1. Careful history
  • 2. Examination
  • 3. Investigations
  • 4. Management and referral
  • 5. Women on Hormonal Therapy
  • 6. Documentation
  • 7. Information for Women
  • SUMMARY TABLE
    • Guidelines For Referral For Investigation
    Of Intermenstrual And Postcoital Bleeding
    These guidelines are issued jointly by The Royal Australian College of Obstetricians and Gynaecologists and the Royal Australian College of General Practitioners, The Australian Society for Colposcopy and Cervical Pathology and the Commonwealth Department of Human Services and Health.
    These guidelines are published to assist general practitioners to decide when it is necessary to refer women with intermenstrual or postcoital bleeding (IMB, PCB) for further tests or to a specialist gynaecologist, and to assist gynaecologists in formulating management plans.

    Genital tract malignancy is an uncommon cause of bleeding at any age and is rare in younger women. Nevertheless it is a possible cause. Since intermenstrual and postcoital bleeding are common, especially in women using hormonal contraception or other hormonal therapies, it is obviously impractical, unreasonably worrying and inappropriate to refer every case for immediate investigation. These guidelines recommend appropriate referral procedures.

    1. Careful history

    Take a careful history noting:
    • patient's age
    • nature, frequency and clinical associations of the bleeding
    • hormonal therapy and contraceptive history
    • past history of bleeding
    • previous Pap smears
    • cigarette smoking
    • sexual history and relevant symptoms in partner

    2. Examination

    Conduct abdominal examination, speculum examination with a good light and bimanual pelvic examination. Check:
    • complete normality of ectocervix
    • contact bleeding and cervical tenderness
    • friability of tissue, ulceration or cervical polyp
    • other possible sites of bleeding
    • signs of vaginal discharge, foreign body or IUCD tail
    Practitioners must always bear in mind the need to re-examine a patient if symptoms recur at a future time.

    3. Investigations

    If the patient has not had a Pap smear within the previous three months, take a Pap smear, using speculum carefully in order not to provoke further bleeding. These diagnostic (rather than screening) Pap smears (Medicare item no. 73055) should be sent to laboratories using appropriate quality control procedures. Cervical swabs should be taken for chlamydia trachomatis, if appropriate.

    Cervical ectropion is a common finding in premenopausal women, especially in combined oral contraceptive users and pregnant women, and contact bleeding from the cervix is relatively common when taking a smear, particularly with a cytobrush from the endocervix.

    The occurrence of contact bleeding or abnormal bleeding in the case history, should be noted on the smear request form. Contact bleeding or ectropion should not prompt referral unless unusual features are present, or IMB or PCB has been persistent. In women with PCB or IMB a negative smear does not rule out the possibility of pathology. IMB and PCB are, by nature, intermittent, and duration, volume and frequency need to be taken into account in determining whether symptoms are "persistent". It is not possible to give a simple and all encompassing definition of "persistent", but for example, several minor episodes over a three month period or two episodes of heavy bleeding should generally prompt referral.

    4. Management and referral

    The following patients should be referred:

    Women with persistent IMB and/or PCB without any unusual features:

    These women should be referred for specialist opinion. In general, hysteroscopy, D and C by a specialist should be the primary diagnostic procedures in women with persistent IMB, while colposcopy should be the primary procedure with persistent PCB or if a suspicious lesion is present on the cervix. Both investigations may be required. In some instances, high-resolution transvaginal ultrasound scanning may provide additional information, but this skilled and expensive technology should not usually be the primary, or the sole, investigation.

    Women with a friable ectropion:

    which is causing persistent symptoms should be referred for assessment and possible treatment. After careful exclusion of significant pathology by colposcopy, hysteroscopy and D and C, a variety of ablative methods may be used.

    Women with IMB/PCB and an abnormal smear:

    These women should be referred for colposcopy if:
    • the smear contains abnormal cells suggestive of CIN-1 or worse, or high-grade glandular abnormalities; or:
    • on repeated diagnostic Pap smear testing 2-3 times over a 12 month period, the smear contains cells suggestive of an underlying low-grade squamous lesion less than CIN-1 (e.g. minor atypia, HPV atypia).
    • Practitioners in remote areas should consider telephone consultation with a specialist if the circumstances are unclear.

    5. Women on Hormonal Therapy

    Women with IMB on the progestogen-only minipill or in the first six months of Depo-Provera treatment (often called breakthrough bleeding) should generally not be referred in the first instance unless bleeding is excessively frequent or prolonged, and provided Pap smears are normal and up to date. Low oestrogen-dose combined pills and IUCDs are also frequent causes of IMB.

    6. Documentation

    Brief documentation as outlined above must be maintained on:
    • type of abnormal bleeding; time since first noted; frequency; associated factors
    • hormonal therapy
    • past history of bleeding and previous investigations
    • date and report of last Pap smear
    • examination findings
    • action taken for investigation and treatment
    • follow-up recommended

    7. Information for Women

    Consideration should be given to the following points in informing women who present with symptoms of IMB or PCB:
    • the most likely cause or causes
    • either that -
    • serious causes like cancer are so rare and other causes so likely that further investigation is not indicated
    • that the cause needs to be investigated
    • instructions about investigations, if indicated
    • when to return for routine review or if symptoms persist
    • that Pap smear is a screening test. It is only 80-90% sensitive, and may therefore not detect underlying pathology in 10-20% of affected women.


    Causes of Irregular Bleeding

    SUMMARY TABLE

    General
    1.1 NormalPeriovulatory bleeding or spotting (which occurs in 1-2% of normal cycles)
    1.2 Luteal Phase DefectSpotting sometimes occurs, but is much less common than with endometriosis
    1.3 Exogenous hormonesBreakthrough bleeding (BTB): this is common with all preparations, especially progesterone alone or with progestogen dominance. BTB is particularly prominent in the first few cycles of treatment, and will usually - but not always - settle; poor compliance is a common cause of BTB.

    · Hormonal contraceptives
    · Hormone replacement therapy
    · Various therapies for gynaecological disease
    · Spironolactone

    1.4 Other drugsSuch as rifampicin and anticonvulsants ( these drugs cause irregular bleeding in women using steriodal therapies of most types, but may cause irregular bleeding even in women on no therapy)
    1.5 Intrauterine Devices Premenstrual spotting is common ; intermenstrual bleeding less so
    1.6 EndometriosisPre and postmenstrual spotting is common
    Uterine
    2.1 Endometrial Polyps Said to be a common cause
    2.2 Intrauterine and Submucous MyomasGenerally cause menorrhagia, but can present with IMB only
    2.3 Endometritis and pelvic inflammatory diseaseCan cause IMB, but frequency is uncertain: superficial endometritis is a diagnosis which has been recognised much more frequently since introduction of diagnostic hysteroscopy
    2.4 Dysfunctional uterine bleedingEspecially anovulatory, is more likely to cause irregular cycles with or without menorrhagia
    2.5 Endometrial and myometrial malignancyUncommon but very important causes of IMB and PCB in younger women
    Lower Genital Tract
    3.1 Benign Cervical LesionsPolyps ; ectropion ; chronic cervicitis - eg. IMB or PCB reported in 18% of women with chlamydia trachomatis cervicitis
    3.2 Malignant Cervical LesionsSquamous ; adenomatous - probably the most important lesions which may present with IMB or PCB. Most of these lesions will cause some irregular bleeding falling within the classification of IMB and PBC, but overall they are uncommon causes of these symptoms).
    3.3 Vaginal LesionsOverall very uncommon causes of IMB and PCB
    Ref: Aust. NZ J Obstet 1996; 36: 1: 73

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