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IMB - Guidelines for referral |
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
Normal | Periovulatory bleeding or spotting
(which occurs in 1-2% of normal cycles) | | 1.2
Luteal Phase Defect | Spotting sometimes
occurs, but is much less common than with endometriosis | | 1.3
Exogenous hormones | Breakthrough 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 drugs | Such 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
Endometriosis | Pre and postmenstrual spotting
is common |
Uterine
| 2.1
Endometrial Polyps | Said to
be a common cause | | 2.2
Intrauterine and Submucous Myomas | Generally
cause menorrhagia, but can present with IMB only | | 2.3
Endometritis and pelvic inflammatory disease | Can
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 bleeding | Especially
anovulatory, is more likely to cause irregular cycles with or without menorrhagia |
| 2.5 Endometrial
and myometrial malignancy | Uncommon
but very important causes of IMB and PCB in younger women |
Lower Genital Tract
| 3.1
Benign Cervical Lesions | Polyps
; ectropion ; chronic cervicitis - eg. IMB or PCB reported in 18% of women
with chlamydia trachomatis cervicitis | | 3.2
Malignant Cervical Lesions | Squamous
; 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 Lesions | Overall very uncommon
causes of IMB and PCB |
Ref: Aust. NZ J Obstet 1996; 36: 1: 73
This page was last built on 19/01/03. It was originally posted on 12/4/98; 8:40:32 AM.
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