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1. Purpose
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This Clinical Practice Guideline provides guidance for the assessment and referral of women with abnormal vaginal bleeding.
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2. Anticipated outcomes
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Women presenting with abnormal vaginal bleeding will receive consistent assessment and appropriate medical referral by the Women’s Health Nurse Practitioner.
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3. Responsibility
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The Women’s Health Nurse Practitioner is responsible for:
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- assessment and referral of women with abnormal vaginal bleeding as required;
- establishment of a process for ensuring follow up of women who fail to attend the required medical consultation.
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4. Definition of terms
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Eligible women are non pregnant women who present with abnormal vaginal bleeding.
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Ineligible women are those presenting with conditions that require urgent medical attention, e.g. acute pain or excessively frequent or prolonged vaginal bleeding or on Tamoxifen therapy.
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| | | Regular heavy menstrual bleeding
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| Excessive amount (>80ml /cycle) or prolonged duration (>7 days/cycle); also called 'menorrhagia' or 'hypermenorrhoea'
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| Occurs at regular intervals
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| | Bleeding or spotting between normal periods
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| Between periods, usually light flow
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| Irregular menstrual bleeding
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| Bleeds less than 21 days or more than 35 days for three cycles or more
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| | | Bleeding following sexual intercourse
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| | | Bleeding 1 year or more following cessation of periods
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4. Process
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4.1 History
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The Women’s Health Nurse Practitioner should take a careful history, documenting the following:
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General
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- age
- current medications including hormonal
- cigarette smoking
- diet and exercise
- drug use (prescription, over the counter, herbal or illicit use)
- height, weight, Body Mass Index.
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Medical
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- thyroid condition
- renal disease
- liver disease
- other medical conditions
- history of epistaxis, easy bruising, episodes of heavy bleeding.
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Gynaecological
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- previous episodes of abnormal vaginal bleeding and previous investigations / management
- Pap test history
- gynaecological surgery
- other gynaecological disorder.
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Obstetric
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- parity
- infertility/sub-fertility
- currently breastfeeding.
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Menstrual
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- last normal menstrual period (LNMP); presence of pregnancy symptoms
- age at menarche and menopause; any post-menopausal bleeding (PMB)
- intermenstrual bleeding (IMB)
- cycle length, duration, estimated amount of flow, presence of clots, any related signs and symptoms (e.g. pain, odour, discharge,) dates and patterns of last three normal menstrual periods.
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Contraceptive
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- recent and current contraceptive use, type, length of time used, any side effects.
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Sexual
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- risk assessment for sexually transmissible infections & blood borne viruses
- post coital bleeding (PCB).
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Family
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- history of breast, endometrial or bowel cancer
- thyroid condition or any other medical condition
- history of abnormal bleeding including known blood dyscrasias, coagulation defects, haemorrhage or bruising.
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4.2 Differential diagnosis
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heavy menstrual bleeding: dysfunctional uterine bleeding, myoma, adenomyosis, endometrial polyps, endometrial hyperplasia, endometrial cancer, hypothyroidism, blood dyscrasias or use of anticoagulants, heavy bleeding associated with intrauterine contraceptive devices, spontaneous miscarriage, endometriosis.
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irregular bleeding or intermenstrual bleeding: endometrial polyps, endometrial hyperplasia, endometrial carcinoma, cervical carcinoma, genital tract infections, “breakthrough bleeding” on oral or injectable contraceptives, ectopic pregnancy, breastfeeding, PCOS
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post coital bleeding: cervical ectropian, , endocervical polyps, chlamydia cervicitis, other genital tract infection, cervical carcinoma, uterine polyps, uterine fibroids, genital tract trauma
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post menopausal bleeding: genital tract trauma associated with urogenital atrophy, exogenous oestrogen/progestogen, endometrial carcinoma, endometrial hyperplasia, endometrial or cervical polyps, urethral caruncle, cervical carcinoma.
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5. Appendices
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5.1 Appendix 1: Algorithm: Abnormal vaginal bleeding management
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| Algorithm: Abnormal vaginal bleeding management
| Click on thumbnail to view full size image of algorithm (pdf 32kb)
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5.1.1 Explanatory notes for use with: Algorithm: Abnormal vaginal bleeding management
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Risk factors for endometrial hyperplasia/carcinoma
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Risk factors for endometrial hyperplasia / carcinoma; weight ≥90 kg, history of infertility, nulliparity, family history breast/endometrial/bowel cancer, age ≥45, exposure to unopposed oestrogens, prolonged exposure to oestrogens e.g. early menarche (<13yo) and late menopause (>55yo), previous tamoxifen use.
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Trans vaginal ultrasound (TVUS)
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For management of PMB, the transvaginal ultrasound must be attended within 21 days of NP consultation. If an ultrasound appointment not available within 21 days, the NP is to discuss with Senior Medical Staff in respect to endometrial sampling in Gynaecology Clinic.
Normal TVUS in a postmenopausal woman demonstrates an endometrial thickness equal to or less than 4mm and no other abnormal finding.
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Pap test
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Women with IMB, PCB or PMB should have repeat Pap smear if previous test was ≥ 3 months ago.
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Post Menopausal Bleeding:
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- women with an abnormal Pap test report in reference to squamous/glandular cells must be referred for an urgent appointment to the Dysplasia clinic
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- women with an abnormal Pap test report in reference to endometrial cells must be referred for an urgent appointment to a senior consultant in the Dysplasia Clinic.
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Progestogen only contraception
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For women with intermenstrual bleeding who are taking progesterone only medicine or who are in the first 6 months of Depo-Provera treatment, seek medical opinion prior to referral.
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Post coital bleeding
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A single episode of post coital bleeding in a woman who has a normal smear and normal cervical appearance does not warrant immediate referral. However where there is persistent or recurrent episodes of post coital bleeding the woman must be referred to the Dysplasia Clinic.
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5.2 Appendix 2: Heavy bleeding chart
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| Heavy bleeding chart
| Click on thumbnail to view full size image (pdf 60kb)
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5.3 Appendix 3: Bleeding: calendar chart
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| Bleeding Calendar Chart
| Click on thumbnail to view full size image (pdf 20kb)
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5.4 Appendix 4: Consumer information
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The Royal Women’s Hospital, Consumer Fact Sheet: Bleeding after the menopause
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http://www.thewomens.org.au/Bleedingafterthemenopause
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Better Health Channel: Menstruation - menorrhagia
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http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Menstruation_menorrhagia?OpenDocument
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myDr, Consumer Medicines Information (CMI), Tranexamic acid http://www.mydr.com.au/drugs/cmi.asp?cmicode=8976&prodcode=032201
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Better Health Channel: Vaginal bleeding - irregular
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http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Vaginal_bleeding_irregular?OpenDocument
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American Family Physician: Information From Your Family Doctor: Abnormal Uterine Bleeding
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http://www.aafp.org/afp/20040415/1931ph.html
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RANZCOG, Patient Education Pamphlets: Heavy Menstrual Bleeding; can be ordered from RANZCOG: http://www.ranzcog.edu.au/publications/pdfs/PIPorderform.pdf
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6. References
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Access references on a separate page: References: Abnormal Vaginal Bleeding: Women's Health Nurse Practitioner Assessment.
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Revised and updated:
13 August 2009
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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