AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 27

How to treat
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inside
What causes
irregular
bleeding?

Assessing
irregular vaginal
bleeding

Management and
referral

Case studies

The authors

DR CHRISTINE READ,
medical director,

IRREGULAR
Family Planning NSW.

vaginal bleeding DR TANIA MAY,

senior clinician and educator in
sexual and reproductive health,
Family Planning NSW.
Background
IN this article, irregular bleeding is noted as stains on the underwear or reproductive hormone feedback of a cohort of ovarian follicles, the
defined as bleeding that occurs out- after toileting. It also includes post- system including the hypothalamus, granulosa cells of which produce
side of the normal menstrual pat- coital bleeding and postmenopausal anterior pituitary gland and ovaries, increased amounts of the hormone
tern. A normal menstrual pattern is bleeding. as well as normal uterine and vagi- oestradiol, which in turn triggers a
taken to be a ‘monthly bleed’. The Amenorrhoea and menorrhagia nal anatomy. surge of luteinising hormone (LH)
cycle length can vary, with a gener- may occur as part of the irregular The menstrual cycle is ‘switched that causes the dominant follicle to
ally accepted normal range of 21- menstrual pattern, but a full discus- on’ at puberty when the hypothala- ovulate. DR MARGARET
35 days and a bleeding duration of sion of these topics is not covered in mus secretes gonadotrophin-releas- As a result of stimulation by STELLINGWERFF,
4-7 days. this article. ing hormone (GnRH). Pulses of this oestradiol, the endometrium thick- medical officer,
Irregular bleeding can consist of hormone cause the release of folli- ens in preparation for implantation Family Planning NSW.
intermenstrual bleeding with a flow The physiology of menstruation cle-stimulating hormone (FSH) from of an embryo, should fertilisation
similar to that of a menstrual A regular menstrual pattern depends the anterior pituitary. and pregnancy occur. The dominant
period. It can be ‘spotting’ that is on the presence of a functioning FSH in turn stimulates the growth cont’d next page

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AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 28

How to treat – irregular vaginal bleeding

from previous page critical factor in assessing the occur at ovulation, about 14 ders were the reason for These women were all inves-
follicle resolves to become the need to investigate or days before the following 19.1% of gynaecological tigated and no pathology
corpus luteum, which then manage an irregular men- menstrual period. consultations over a two- was found.
produces the hormone prog- strual pattern. If there is a luteal phase year period and that 25% of A study looking at refer-
esterone as well as oestradiol. During puberty and the defect, spotting can occur gynaecological surgery rals to a gynaecology depart-
If a pregnancy does not perimenopause — the premenstrually each month, involved abnormal uterine ment for postcoital bleeding
1
eventuate, the corpus luteum extremes of reproductive life said to be due to a lack of bleeding. reviewed the records of 248
becomes non-functional and — regular menstruation may progesterone. However, However, the incidence of women referred over a five-
stops producing hormones, not be recognisable. In both endometriosis is a more irregular bleeding is low over- year period and found that
causing the breakdown of these transitional phases common diagnosis for all, and the incidence of sig- benign polyps (including
the endometrium and men- anovulatory cycles occur, episodes of spotting or nificant pathology is also low, endometrial polyps) were
strual bleeding starts. leading to failure to estab- bleeding that occur in the making the issue a difficult found in 20% of cases, 25%
lish a distinct ‘withdrawal’ days leading up to menstru- one in terms of how much had a cervical ectropion,
Irregular bleeding — menstrual bleed. With con- ation. investigation is warranted. while cervical intraepithelial
what can be normal? tinued endometrial stimula- In a study of menstruation neoplasia was detected in
3
It is important to understand tion there is often an irregu- How common is irregular in 621 normal women over 6.8% of cases.
that menstrual patterns that lar and sometimes heavy and vaginal bleeding? 20,672 cycles, intermen- Intermenstrual or post-
do not conform to the regu- prolonged breakdown of the Women commonly present strual bleeding was reported coital bleeding has been
lar cycling discussed above endometrial lining. to their doctor for bleeding in 100 cycles (39 women; reported in 13% of women
can be a normal occurrence. In periovulatory bleeding, problems. One study in the 6.3% of the women studied diagnosed with chlamydial
2
The age of the woman is a bleeding or spotting can US found menstrual disor- and 0.5% of cycles studied). cervicitis.

What causes irregular bleeding?

IT is beyond the scope of this arti- Figure 1: Endometrial hyperplasia and carcinoma. Table 2: Relation of age to common causes of irregular bleeding
cle to give an exhaustive coverage (Image courtesy of Dr Glenn McNally of Warren and McNally Ultrasound, Sydney.)
of all the causes of abnormal bleed- Age group
ing. We have attempted to high- 15-20 20-30 30-45 45-55 55+
light causes that are relatively STIs: cervicitis (especially chlamydia) HRT
common and straightforward to Cervical ectropion Endometrial cancer
manage, as well as illustrating the Endometrial polyps
more serious conditions that may Endometrial hyperplasia
present as irregular bleeding. Uterine fibroids
Of the causative factors listed in Intrauterine devices
table 1, the most common are use Pregnancy and complications: miscarriage/ectopic pregnancy
of hormones, either as contracep- Contraceptive steroids (especially progestogens)
tion or menopausal hormone ther- Endometriosis
apy, pregnancy, endometrial Trauma/surgery
hyperplasia, cervical ectropion and
cervicitis. The causes of irregular Table 3: Changes to bleeding pattern with use of steroidal
bleeding tend to be related to age hormones
Figure 2: Cervical cancer.
and stage of reproductive life (table Cervical cancer: a
cautionary tale Steroidal hormone Bleeding problem
2).
A 22-YEAR-old woman presented Combined oestrogen and Break-through bleeding may happen:
to a gynaecologist with break- progestogen contraceptives ■ In the first 3-4 months of use
Exogenous hormones and
through bleeding while using the (pills and vaginal ring) ■ After missed pills or delay in inserting rings
menstruation
■ After episodes of vomiting or diarrhoea
The physiological menstrual cycle combined OCP. A Pap test was
■ With concomitant use with
is particularly dependent on the done and reported as normal.
Several times over the following liver-enzyme-inducing drugs*
pattern of hormonal biofeedback
systems that connect the function- year the patient presented to a GP, Progestogen-only All associated with irregular bleeding patterns,
ing of the hypothalamus, pituitary with a history of intermittent break- contraceptives (pills, which may include episodes of amenorrhoea,
and ovary. through bleeding and postcoital injectable depot spot bleeding and prolonged, frequent bleeding.
Exogenous hormones, particu- bleeding while taking the pill. A medroxyprogesterone Note that the effect of DMPA may persist for
larly in the form of steroidal con- repeat Pap test reported monilia acetate [DMPA], implant up to 12 months
traceptives or menopausal hor- and mild squamous atypia, [Implanon] and
mone therapy, are a potent possibly due to inflammation, with levonorgestrel IUD [Mirena])
influence on this system, and an a recommendation to repeat in 3-6 HRT — cyclical Expect a monthly bleed, but women may
ensuing irregular cycle is not nec- months. experience breakthrough of their natural cycle in
essarily a sign of abnormality. It is The patient continued to note the perimenopause
Table 1: Causes of irregular
therefore important to know the variable postcoital bleeding and HRT — continuous Designed to be ‘bleed free’, but women may
bleeding
menstrual changes expected with presented to another GP. She was (including tibolone) have break-through bleeding in the
General perimenopause (for this reason it is not indicated
the administration of steroidal con- then referred to a gynaecologist.
■ Contraceptives — hormonal
traceptives and HRT (table 3). The gynaecologist found an eroded for use 12-18 months after menopause)
contraceptive methods and
Because irregular vaginal bleed- and friable cervix with contact *Carbamazepine, oxcarbamazepine, phenobarbital, phenytoin, primidone, topiramate
intrauterine devices
ing in women using hormonal con- bleeding. Biopsy confirmed rifampicin and rifabutin protease inhibitors, non-nucleoside reverse-transcriptase
■ Menopausal hormone therapy,
traception or other hormonal ther- malignancy. inhibitors, griseofulvin and St John’s wort may interfere with drug metabolism in the liver
including with tibolone, in a
apies is common (usually known Review of the previous Pap test
woman with an intact uterus
as break-through bleeding), it is indicated abnormal cells, including Table 4: Important ‘not to miss’ causes of irregular bleeding
■ Endometriosis — may cause
obviously impractical, unreason- CIN 3. The patient went on to have
pre- and postmenstrual spotting. 15-20 20-30 30-45 45-55 55+ (Years)
ably worrying and inappropriate a radical hysterectomy for stage 1b
Generally presents with Chlamydia/PID Endometrial/ovarian cancer
to refer every case for immediate carcinoma of the cervix. Despite
dysmenorrhoea, which Pregnancy and pregnancy complications
investigation. further surgery, radiotherapy and
worsens with time Endometrial polyps
It may be appropriate to stop the chemotherapy over several years,
Uterine Endometrial hyperplasia
hormonal medication for 2-3 she died of metastatic disease.
■ Endometrial polyps Cervical cancer
months, making sure that if con-
■ Endometrial hyperplasia
traception is needed another
■ Fibroids — generally cause
method, such as condoms, is used uncommon cause of bleeding at 50-70 and is rare in those under of 1.7 per 100,000 women.
during this time. If the bleeding menorrhagia but can present with any age and is rare in younger 40. While the occurrence of inter-
problem persists, it should be inves- intermenstrual bleeding women. Risk factors include age >40, menstrual or postcoital bleeding as
■ Pregnancy — ectopic, early
tigated. weight >90kg, prolonged exposure a presenting symptom in cervical
While the rate of significant pregnancy loss Endometrial hyperplasia and to endogenous or exogenous unop- cancer is low, it should not be
■ Endometritis — postnatal and
pathology (particularly malignancy carcinoma posed oestrogen. ignored. The case study above left
in the reproductive age group) is postsurgical This is the most common invasive provides a cautionary tale for GPs
■ Endometrial/myometrial
low, there are good reasons to con- gynaecological cancer in Australia Cervical cancer and led to the development of the
sider serious causes when irregular malignancy (figure 1), ranking sixth in terms The incidence of cervical cancer Guidelines for Referral for Investi-
bleeding is a presenting symptom. Lower genital tract of incident cancers in women. It (figure 2) in Australia has been gation of Intermenstrual and Post-
The age of the woman is an impor- ■ Cervical ectropion results in about 1400 new cases dramatically reduced as a result coital Bleeding, by the Royal Aus-
tant factor in assessing her risk (see ■ Cervical polyps and 260 deaths every year. Risk of the cervical screening program. tralian and New Zealand College
table 4). ■ Cervicitis increases with age. It is most com- The incidence in 2002 was 6.9 per of Obstetricians and Gynaecolo-
4
Genital tract malignancy is an ■ Cervical malignancy monly diagnosed in women aged 100,000 women, with a mortality gists (RANZCOG).

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AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 29

Assessing irregular vaginal bleeding

History Figure 3: Algorithm for investigating intermenstrual and postcoital bleeding.
IMPORTANT signposts in
history taking include:
■ The woman’s age and stage

of reproductive life.
Investigating intermenstrual or postcoital bleeding
■ History of bleeding (how
Is the patient pregnant?
often, what time of the
month, postcoital, etc).
■ Risk of pregnancy/recent

delivery/recent gynaecolog- YES NO

ical surgery or instrumen- Exclude ectopic pregnancy and manage any Is there a iatrogenic cause, eg,
tation. complications of uterine pregnancy combined OCP, recent colposcopy
■ Use of hormonal therapy

and contraceptive history.

■ Previous abnormal Pap YES NO
tests. ■ Check Pap test up to date Look for pathological cause
■ Sexual history, including ■ Screen for chlamydia if ≤25 and risk factors If bleeding persists
risk for sexually transmis- ■ Discuss and cease or modify medication

sible infections, and rele-

vant partner history.
■ Previous history of STIs.
? Cervix ? Uterine
Figure 3 presents a flow
chart for investigating inter- Speculum exam Endometriosis Bimanual pelvic
menstrual and postcoital Pap test Laparoscopy examination
bleeding.
Speculum exam looking for:
Swabs Ultrasound
■ Ectropion

■ Endocervical polyp
Non-screening Pap Swabs for infection Hysteroscopy
Examination
■ Cervicitis
test looking for: (especially think of Endometrial
Conduct a speculum exami-
■ Cervical dysplasia chlamydia PCR)
nation with a good light and ■ IUD tail sampling for
look for: histopathology
■ Ectropion and contact

bleeding on the cervix.

■ Friability of tissue or ulcer- ■ Cervical swabs should be uterus, uterine size and obe-
ation of the cervix.
Important practice points taken for Chlamydia tra- sity can limit its sensitivity.
■ Presence of cervical polyps. chomatis if appropriate. Saline infusion sonohys-
■ Intermenstrual bleeding and postcoital bleeding are by nature intermittent, and duration, volume
■ Other possible sites of terography (SIS) can clarify
and frequency need to be taken into account in determining whether symptoms are ‘persistent’. It
bleeding. is not possible to give a simple and all-encompassing definition of ‘persistent’ but, for example, Ultrasound imaging the contours, symmetry and
■ Signs of vaginal discharge, High-resolution transvaginal thickness of the endometrium.
several minor episodes over a three-month period, or two episodes of heavy bleeding, should
foreign body or IUD tail. generally prompt referral. If there is uncertainty, it may be useful to ask a woman to keep a ultrasound can be a useful A thin catheter is inserted
■ If pregnant, whether the cer- additional test in investigating through the cervix and 20mL
menstrual diary so that you can make an assessment of the frequency and timing of her bleeding.
vical os is open or closed. ■ Cervical ectopy (ectropion) is a common finding in premenopausal women, especially in
abnormal bleeding when an of saline instilled, which dis-
Perform an abdominal combined OCP users and pregnant women. Contact bleeding or ectopy should not prompt endometrial cause is sus- tends the uterine cavity.
and bimanual pelvic exami- referral unless other features are present or intermenstrual or postcoital bleeding have been pected. It permits the endome- SIS is particularly valuable
nation, assessing: persistent. trial texture to be assessed, as in detecting endometrial
■ Tenderness on rocking the well as the myometrium and polyps that are not apparent
■ In women with intermenstrual or postcoital bleeding, a negative smear does not rule out the
cervix. possibility of pathology. ovaries. The addition of on a standard ultrasound
■ Size of the uterus. colour or power Doppler and it more clearly delineates
■ The Pap smear is a screening test, not a diagnostic test, and is only 80-90% sensitive and may
■ Adnexal masses/tenderness. assists in detecting vascular areas of endometrial thick-
therefore not detect underlying pathology in 10-20% of affected women.
■ Practitioners should always bear in mind the need to re-examine the woman if bleeding recurs.
abnormalities, including neo- ening and irregularity.
Investigations for ■ Pregnancy testing in women of childbearing age is important to exclude pregnancy complications
vascularisation, which may be The sensitivity of SIS can
intermenstrual and as a cause of irregular bleeding. associated with malignancy. be similar to that of hys-
postcoital bleeding ■ In some instances high-resolution transvaginal ultrasound scanning may provide additional
Focal thickening of the teroscopy. In experienced
The information presented information, and saline infusion sonohysterography may also be useful (see right) endometrium can be sugges- hands it has been found to
in this section is adapted ■ It is important to keep adequate documentation in the clinical notes on the type of abnormal
tive of polyps, and submu- have a sensitivity of 80-
from the RANZCOG guide- bleeding, any hormonal therapy being used, any past history of bleeding and previous cosal fibroids may distort the 100% and a specificity of
4
lines: investigations, the date and report of the last Pap smear, examination findings, action taken for endometrial stripe, while 76-96% for detecting
■ If the patient has not had a global thickening of the intrauterine pathology.
investigation and treatment, and the follow-up recommended.
Pap smear within the pre- endometrium can be indica- A more recent technique
vious three months, take a tive of hyperplasia, and gross is hysterosalpingo-contrast-
Pap smear using the specu- ity control procedures. also be sent if bleeding is myometrial involvement is sonography (hy-co-sy). This
lum carefully so as not to Contact bleeding from the likely to obscure the cells suggestive of malignancy. technique, using a special
provoke further bleeding. cervix is relatively common on the slide. The occurrence Unenhanced endovaginal occlusive catheter and either
These diagnostic (rather when taking a smear, par- of contact bleeding or ultrasonography is non-inva- ultrasonic contrast agent or
than screening) Pap smears ticularly from the endo- abnormal bleeding in the sive and convenient, but fac- a mix of air and saline, is
should be sent to laborato- cervix using a cytobrush. A case history should be tors such as residual bladder also capable of assessing
ries using appropriate qual- ThinPrep sample should noted on the request form. volume, the orientation of the tubal patency.

Management and referral

Persistent intermenstrual Women with a friable cervix ■ The smear report suggests the tation with a specialist if the cir-
and/or postcoital bleeding When this is causing persistent presence of CIN-1 (low-grade cumstances are unclear.
without any unusual features symptoms, women should be squamous intraepithelial lesion
WOMEN with persistent bleeding referred for assessment and possi- [LSIL]) or a higher grade abnor- Women using hormonal therapy
— even if Pap smears and other ble treatment. After careful exclu- mality or the presence of any glan- Women with intermenstrual
tests are normal and regardless of sion of significant pathology by dular abnormality. bleeding who are on the
whether or not an ectropion is pre- colposcopy, a variety of ablative ■ On repeated diagnostic Pap smear progestogen-only minipill or in
sent — should be referred for spe- methods may be used. Generally testing 2-3 times over a 12-month the first six months of Depo-
cialist opinion. the problem will resolve without period, the smear contains cells Provera treatment (often called
In general, a hysteroscopy/D&C treatment. suggestive of an underlying squa- break-through bleeding) should
by a specialist should be the primary mous lesion of lower grade than generally not be referred in the
procedure in women with persistent Intermenstrual or CIN-1 (possible LSIL). first instance unless bleeding is
intermenstrual bleeding, while col- postcoital bleeding and an However, if bleeding is persis- excessively frequent or pro-
poscopy should be the primary pro- abnormal Pap smear tent, immediate referral is longed, and provided Pap smears
cedure with persistent postcoital Even if these women have minor needed, as per the first guideline are normal and up to date.
bleeding or if a suspicious lesion is intermittent episodes of bleeding above. Low-oestrogen-dose combined
present on the cervix. Both investiga- (ie, not ‘persistent’) they should be Practitioners in remote areas pills and IUDs are also frequent
tions may be required. referred for colposcopy if: should consider telephone consul- cont’d next page

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How to treat – irregular vaginal bleeding

from previous page Figure 4: Transformation zone of the cervix.

causes of intermenstrual
bleeding, especially in the Time period Position of the External appearance of the Sampling
first few months of use. transformation zone, cervix when viewed with a
endocervical canal and speculum
Columnar cells cervix
Postmenopausal bleeding
When a woman presents Area of metaplasia
During puberty,
with a history of post- (transformation zone)
pregnancy and when
on the OCP when External os of Cervix sampler
menopausal bleeding (more endocervical
Original squamo- oestrogen levels are (or spatula
than 12 months since columnar junction canal
high alone)
menopause), referral should
Cells lining
be made for transvaginal
Squamous cells endocervical During reproductive
ultrasound. If the ultrasound External os of Cervix sampler
canal life
reveals that the endometrial endocervical (or spatula
Transformation zone canal alone)
stripe is homogenous and Cells on
ectocervix
uniformly 5mm or less, no
further evaluation is gener- When oestrogen Cervix sampler
levels are low, External os of
ally required. The likelihood endocervical (or spatula) and
eg, menopause, cytobrush
of missing a significant breastfeeding canal
endometrial abnormality is
very low (0.1% in HRT
users and 1% in non-users). Is your patient pregnant? Serum pregnancy testing to be associated with a poor The diagnosis of a threat- ■ Ectopic pregnancy.
Tamoxifen can increase Ectopic pregnancy or offers little advantage over pregnancy outcome (eg, ened miscarriage does not ■ Chorionic villus sampling.
the risk of endometrial miscarriage these sensitive urine tests. spontaneous abortion or always require hospital Beyond 12 weeks, a higher
cancer. When a woman Pregnancy should be In modern practice, trans- ectopic pregnancy), while a admission and raises the dose of RhD immunoglobulin
taking tamoxifen presents excluded when a woman of vaginal ultrasonography is level >60nmol/L is associated question of whether GPs is used.
with postmenopausal bleed- childbearing age at risk of the diagnostic tool of choice with a probable viable preg- should consider the prophy- There is insufficient evidence
ing, prompt referral should pregnancy presents with for detecting an intrauterine nancy (based on levels used lactic use of RhD immuno- to support the use of RhD
be made for transvaginal irregular bleeding and/or or ectopic pregnancy in the by the Early Pregnancy globulin in this circumstance. immunoglobulin for bleeding
ultrasound, as above. abdominal pain. A simple presence of a positive preg- Assessment Service, Royal A dose of 250IU (50µg) before 12 weeks’ gestation in
qualitative urine dipstick test nancy test. Prince Alfred Hospital, RhD immunoglobulin (anti-D) an ongoing pregnancy.
Recurrent postmenopausal for human chorionic gon- A single progesterone level Sydney, NSW). should be offered to every For successful immuno-
bleeding adotrophin is quick, easy can be helpful in predicting Early diagnosis and referral RhD-negative woman with no prophylaxis, RhD immuno-
A postmenopausal woman and sensitive. pregnancy outcome in the to an early pregnancy unit preformed anti-D to ensure globulin should be adminis-
with a normal transvaginal Even if a woman reports first eight weeks of gestation where possible allows the clin- adequate protection against tered as soon as possible
ultrasound report and per- a normal period within the and may be useful in women ician to consider conservative immunisation for the follow- after the sensitising event,
sistent bleeding should be last four weeks, a negative who have a positive preg- management options such as ing indications, up to and but always within 72 hours.
further investigated by hys- urine pregnancy test will nancy test and no uterine sac methotrexate, or an expectant including 12 weeks’ gestation: If RhD immunoglobulin has
teroscopy/D&C/endometrial exclude a clinically signifi- on ultrasound. approach for ectopic preg- ■ Miscarriage. not been offered within 72
biopsy. cant ectopic pregnancy. A level <20nmol/L is likely nancy. ■ Termination of pregnancy. hours, a dose within 9-10

Confidence

†1 patient-year of experience = 1 patient on LIPITOR therapy for 1 year. LIPITOR is indicated as an adjunct to diet for the treatment of patients with hypercholesterolaemia. Also indicated in hypertensive
patients with risk factors for heart disease to reduce risk of non-fatal myocardial infarction and non-fatal stroke. Refer to Product Information before prescribing. The full disclosure Product Information
is available on request from Pfizer Australia Pty Ltd. LIPITOR (atorvastatin calcium). Supplier: Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38–42 Wharf Road, West Ryde NSW 2114. Pfizer Medical Affairs 1800 675 229. Dosage and administration:
10–80mg/day as a single daily dose. LIPITOR can be taken at any time of the day, with or without food. Contraindications: Hypersensitivity to any component of this medication; active liver disease or unexplained persistent elevations of serum transaminases;
pregnancy and lactation. Women of child-bearing potential, unless on an effective contraceptive and highly unlikely to conceive. Precautions: Patients who consume substantial quantities of alcohol and/or have a history of liver disease; Myopathy (monitor CK); Risk
factors predisposing to development of renal failure secondary to rhabdomyolysis; Use of concomitant medication that may reduce activity/ levels of steroid hormones (ketoconazole, spironolactone and cimetidine); Interactions with other medicines: inhibitors of

30 | Australian Doctor | 18 May 2007 www.australiandoctor.com.au

AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 31

days may offer some protec- Figure 5: Cervicitis. always postcoital, the bleed- chomatis is the most pregnancy. (NB: azithro-
tion. ing is most likely due to the common sexually transmis- mycin is indicated only for
ectropion. sible bacterial pathogen in cervicitis and is not at pre-
Cervical ectropion However, if there is any Australia. There were sent indicated for the man-
In the past, cervical ectopy, doubt about the ectropion 36,100 notifications in Aus- agement of PID).
or cervical ectropion, was being responsible for the tralia in 2004. ■ Doxycycline 100mg twice

known as cervical erosion. It bleeding, it is preferable to Between 10% and 40% of daily for 10 days. Alert
is the transformation zone of refer for further investiga- chlamydial infections in patients to the risk of pho-
the cervix (figure 4), visible tion. In any case if the bleed- women can lead to pelvic tosensitivity. Doxycycline is
on the ectocervix. It is seen ing is regularly present after inflammatory disease (PID) contraindicated during
when, due to hormonal intercourse (ie, persistent), if left untreated; of those pregnancy and/or breast-
changes, the columnar referral is appropriate as per with PID, up to 20% may feeding (discoloration of
epithelium moves onto the the guidelines above. become infertile. permanent teeth).
vaginal portion of the cervix. Indications for testing for ■ Roxithromycin 150mg bd

A cervical ectropion looks Cervicitis chlamydia include: or 300mg daily as a single

red and may appear Inflammation of the cervix, ■ Mucopurulent discharge dose for 10 days.
inflamed because the colum- or cervicitis (figure 5), may from the cervix. In pregnant women ery-
nar epithelium is thinner be responsible for postcoital ■ An inflamed friable ectro- thromycin should be used in
than the squamous epithe- or intermenstrual bleeding. pion with contact bleeding. place of doxycycline at a
lium, making the underlying Depending on the cause of ■ Suspected PID. dose of 800mg bd for 10
blood vessels more apparent. the inflammation there may ■ Sterile pyuria. days. If this dose is not tol-
The columnar epithelium be associated symptoms such In the absence of national erated, 250mg qid for 10
may also secrete more as vaginal discharge, pain guidelines, opportunistic days can be used. Alterna-
mucus, which sometimes with intercourse or odour. testing has been recom- tively, give roxithromycin
causes a vaginal discharge The most common sexu- mended for all sexually 150mg bd or 300mg daily
This is a normal finding in ally transmissible infection active women aged 25 or for 10 days.
high-oestrogen states, such causing cervicitis is chlamy- younger, pregnant, or who General advice includes:
as being young, during preg- dia, and this should be report a new sexual partner ■ Limit or stop alcohol con-

nancy and in women using actively searched for. Gon- within the past 12 months sumption while on medica-
oestrogen therapy, including orrhoea, trichomonas and and are not using condoms tion.
5,6
the combined OCP. genital herpes are other all the time. ■ Partners should be given

Contact bleeding is It is not easy to determine possible causes. Cervicitis Treatment options for treatment regardless of
common with this condition, whether an ectropion found may also be due to allergic chlamydial cervicitis and whether or not they show
as the ectropion can bleed on clinical examination can reactions and to bacterial urethritis include: infection on testing.
easily with minimal trauma be attributed as the cause of vaginosos. ■ Azithromycin 1g orally ■ Advise abstinence from

such as penetrative sexual intermenstrual or postcoital once (preferred treatment). sexual intercourse until
intercourse, inserting a bleeding. If an ectropion Chlamydia It is important that the part- seven days after both part-
speculum or taking a Pap bleeds easily on a Pap test or Chlamydiae are specialised, ner takes the treatment at ners have completed their
test. The condition regresses by brushing over it with a intracellular Gram-negative the same time. Azithro- treatments, even if taken at
with age. swab and the bleeding is bacteria. Chlamydia tra- mycin may be taken during the same time.

OVER 139,000,000
1–4†
patient - years of experience

atorvastatin calcium

cytochrome P450 3A4, other HMG-CoA reductase inhibitors, antacid, colestipol, erythromycin/clarithromycin, protease inhibitors, digoxin, oral contraceptives. Adverse reactions: Headache, asthenia, abdominal pain, dyspepsia, nausea, flatulence,
constipation, diarrhoea, insomnia, myalgia. Full disclosure Product Information approved by the TGA on 27 January 2005. Date of most recent amendment: 13 July 2006. PBS dispensed price, April 2007: 10mg $40.11; 20mg $56.73; 40mg
$77.78; 80mg $108.98. References: 1. IMS Health (Aust) Ltd, MAT unit share data, May 2005. 2. IMS Health MIDAS, MAT unit share data, December 2004. 3. IMS Global, data through fourth quarter 2006. 4. IMS monthly data January through May 2005. LIPITOR* Reg Trademark Pfizer Inc. www.pfizer.com.au 04/07 PFXLI7125

PBS Information: Restricted benefit. For use in patients that meet the criteria set out in the General Statement for Lipid-Lowering Drugs.

www.australiandoctor.com.au 18 May 2007 | Australian Doctor | 31

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How to treat – irregular vaginal bleeding

References
1. Nicholson WK, et al.
Authors’ case studies
Patterns of ambulatory care
use for gynecologic conditions:
Intermenstrual bleeding Figure 6: Endometrial fibroid and polyp.
a national study. American
in a young woman (Image courtesy of Dr Glenn McNally of Warren and McNally Ultrasound, Sydney.)
Journal of Obstetrics and
SARAH, 15, presents
Gynecology 2001; 184:523-
because she is concerned she
30.
is pregnant. She had previ-
2. Vollman RF. The Menstrual
ously been on the OCP but
Cycle. WB Saunders,
had run out four months
Philadelphia, 1977.
previously. She had been in a
3. Selo-Ojeme D, et al. A
new sexual relationship for
clinico-pathological study of
one month and was only
postcoital bleeding. Archives of
using condoms some of the
Gynecology and Obstetrics
time.
2004; 270:34-36.
Her last menstrual period
4. The Royal Australian &
had been three weeks previ-
New Zealand College of
ously, her last episode of Summary
Obstetricians &
unprotected sex two weeks
previously, and she had had ■ Always exclude
Gynaecologists. College pregnancy in a woman of
statement C-Gyn 6. Guidelines
two days of spotting one
week before her presenta- reproductive age.
for Referral for Investigation of
tion. She had had a urine ■ Irregular vaginal bleeding
Intermenstrual and Postcoital
pregnancy test, which was is commonly associated
Bleeding. July 2004 [cited 7
negative, and a urine sent off with hormone-containing
February 2007]. Available
for a chlamydia PCR. medications.
from: www.ranzcog.edu.au/
publications/statements/
Sarah’s chlamydia test ■ Assess risk of chlamydia.
C-gyn6.pdf
came back positive. She was
■ Look at the cervix for
5. Chen YM, Donovan B.
recalled for treatment with
signs of lesions that could
Genital Chlamydia trachomatis
azithromycin 1g stat and
bleed.
infection in Australia:
advised to tell her current Practice tips — bleeding while using hormonal contraception
partner so he could be tested ■ Is the Pap test normal?
epidemiology and clinical
and treated as well. ■ Exclude underlying causes: pregnancy, chlamydia, missed pills, vomiting or diarrhoea, concomitant ■ Ask the woman to keep a
implications. Sexual Health
medications. menstrual diary for three
2004; 1:189-96.
6. Harris M, et al (editors).
Intermenstrual bleeding ■ Is the Pap test normal? months and place her on a
Guidelines for preventive
in a middle-aged woman ■ Increase the oestrogen dose if the patient is taking the combined OCP, or change the progestogen recall system.
activities in general practice.
Mary, 39, presented with a to either a 1mg norethisterone combined OCP or a desogestrel- or gestodene-containing combined ■ If irregular bleeding is
6th edn. Royal Australian
small amount of bleeding OCP. persistent, refer for
College of General
lasting one day, occurring specialist assessment.
■ Progesterone-only OCP methods can cause irregular bleeding. In women who are not
Practitioners, Melbourne,
about a week before her
contraindicated to using oestrogen, additional oestrogen for women using Depo Provera or Implanon ■ Bleeding that occurs more
2005.
period. Her vaginal dis-
may help. than 12 months after the
7. Federal Health Department.
charge was different —
Stopping the hormonal contraception for some months and using condoms will indicate whether the menopause requires
National Sexually
“vinegary”. She had been in ■

bleeding is related to the hormonal contraceptive. investigation.

Transmissible Infections
the same monogamous rela-
Strategy 2005-2008. Federal
tionship for 14 years. She
Health Department, Canberra,
had no postcoital bleeding. stromal invasion of <1mm. trial hyperplasia with mild three months ago and this
2005.
Many years earlier she Mary was advised to have a atypia. was reported as normal. At
had had two atypical Pap hysterectomy, in view of the Because Naomi was trying the time Mei started to use Guidelines
Online resources smears, which had needed nature of the lesion. to fall pregnant the decision the Loette she started a new ■ In women with
■ Guidelines for the use of Rh
no treatment, and all bien- She had a radical, modi- was made to allow her a sexual relationship and said intermenstrual or
D Immunoglobulin (Anti-D)
nial Pap smears since then fied vaginal hysterectomy short period of time for this she uses condoms inconsis- postcoital bleeding, a
in Obstetrics in Australia,
had been negative. Mary without complications. No to happen and then to repeat tently. negative smear does not
College Statement C-Obs 6
had experienced minor residual carcinoma was iden- her hysteroscopy. She failed A speculum examination rule out the possibility of
RANZCOG March 2006:
amounts of pre- and post- tified in the cervix. There was to fall pregnant and had a reveals an ectropion but pathology (RANZCOG
www.ranzcog.edu.au
menstrual spotting close to no obvious parametrial or repeat hysteroscopy eight there is no contact bleeding 4
guidelines ).
■ National library for health
her period, but this most lymphatic spread. Mary will months later. This time a or unusual features. The his-
■ It is important to exclude
clinical knowledge
recent intermenstrual bleed- continue to have annual vault repeat biopsy showed a tory of unprotected sex and
chlamydia as a cause of
summaries:
ing was different. smears for 10 years for stage grade 1 well-differentiated Mei’s age indicate the need
intermenstrual and post-
www.cks.library.nhs.uk/
Physical examination was 1A carcinoma of the cervix. adenocarcinoma. She was to exclude chlamydia. A cer-
coital bleeding, as it is
clinical_knowledge
normal. The cervix appeared referred to a specialist vical swab sent to pathology
common, can lead to PID
■ Royal College of
healthy and the vaginal dis- Intermenstrual bleeding gynaeoncology unit. for chlamydia PCR testing is
if left untreated and, of
Obstetricians and
charge was normal. A non- persisting after stopping At operation Naomi was reported as negative.
patients with PID, up to
Gynaecologists. National
screening Pap smear was a progesterone-only pill found to have stage 3C ade- A negative chlamydia test
20% may become infertile
Evidence-Based Clinical
taken and a high-resolution Naomi was 41 when she nocarcinoma with involve- and a screening Pap test that
(from National Sexually
Guidelines: The Initial
ultrasound requested. A high- presented with an 18-month ment of the obturator and was normal three months
Transmissible Infections
Management of
vaginal swab for microscopy history of abnormal vaginal para-aortic lymph nodes. ago, combined with a his- 7
Strategy 2005-08 ).
Menorrhagia, 2006:
and culture and a cervical bleeding. She had been using She had total abdominal tory of no bleeding until
swab for chlamydia PCR was the progesterone-only pill for hysterectomy and bilateral starting to take Loette, indi- ■ Opportunistic testing for
www.rcog.org.uk/index.asp?
taken although Mary was at a contraception because she salpingo-oophorectomy as cate that the OCP may be chlamydia has been
PageID=698.
very low risk of an infection. was a smoker and unable to well as adjuvant radiother- the cause of the bleeding. recommended for all
■ New Zealand Guidelines
The ultrasound did not take the combined OCP. She apy. She had no signs of Loette is a low-dose com- sexually active women
Group. Heavy Menstrual
reveal any focal abnormal- had developed irregular recurrence four years after bined OCP containing 20µg ≤25, or who are pregnant,
Bleeding. www.nzgg.org.nz
ity that could account for bleeding while using the her surgery. ethinyloestradiol and 100µg or who report a new
■ Royal College of
the bleeding, and vaginal progesterone-only pill, which levonorgestrel. The low dose sexual partner within the
Obstetricians and
and cervical swabs were neg- persisted when she stopped. A 23-year-old on the of oestrogen means cycle past 12 months and are
Gynaecologists. National
ative, as expected. However, Naomi was getting a combined OCP with control is very vulnerable to not using condoms all the
Evidence-Based Clinical 6
the Pap smear detected a period every 21 days but intermenstrual bleeding any situations where pills are time (RACGP guidelines ).
Guidelines. The Management
of Menorrhagia in Secondary
high-grade epithelial abnor- after the period finished she Mei had been taking Loette missed, vomiting or diar- ■ Women with persistent
Care; The Initial
mality (CIN3). was left with a smelly dis- for four months. She rhoea occurs or concomitant minor episodes of
Management of
Mary was referred for col- charge and light spotting. A reported that she has had liver-enzyme-inducing drugs bleeding over a
Menorrhagia.
poscopy. Macroscopically pelvic ultrasound showed a some bleeding each month are used. three-month period or
www.rcog.org.uk/index.
the cervix was normal but complex echogenic lesion in while taking the three weeks However, Mei was sure two episodes of heavy
asp?PageID=1046
application of acetic acid the right fundal region. Hys- of active hormone pills. She she was taking her pills prop- bleeding should be
■ Royal Women’s Hospital.
showed dense aceto-white teroscopy was recommended had a withdrawal bleed each erly, so it seemed useful to referred for investigation
4
Women’s Health Nurse
areas with punctation and to exclude sub-mucous month as well. try switching to a 30µg (RANZCOG guidelines ).
Practitioner Assessment
mosaic change consistent fibroid or endometrial polyp Before starting the pill Mei ethinyloestradiol pill, such as ■ Investigation of irregular
Clinical Practice Guidelines.
with high-grade dysplasia. (figure 6). was using condoms for con- Microgynon 30 or Yasmin. vaginal bleeding may
Abnormal Vaginal Bleeding.
Biopsy revealed extensive At hysteroscopy Naomi traception and did not have On review four months later, include transvaginal
www.rwh.org.au/rwhcpg/
adenocarcinoma in situ, with was found to have a sub- any intermenstrual bleeding. Mei reported that, with the ultrasound, colposcopy,
womenshealth.cfm?doc_id=
features suggestive of early mucous fibroid with reason- There had not been any change of pill, there had been hysteroscopy and D&C.
6068
invasion. Histopathology on ably normal material around postcoital bleeding. A no irregular bleeding while (RANZCOG guidelines ).
4

core biopsy confirmed early it. A biopsy showed endome- screening Pap test was taken taking the active pills.

32 | Australian Doctor | 18 May 2007 www.australiandoctor.com.au

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How to treat – irregular vaginal bleeding

GP’s contribution
current contraception was ment after history-taking public health unit of the posi- ment makes any difference
Depo-Provera (which made and basic examination in the tive result. It is important that to long-term management of
her amenorrhoeic) and she absence of diagnostic testing, we do have an epidemiologi- bleeding problems with
used condoms — sometimes! with a combination of drugs cal picture of this increasingly either Depo Provera or
On examination, Estelle known to treat organisms common disease, so GPs Implanon.
had one (new) clitoral and responsible for that syn- should be alert to the possi-
numerous labial piercings, drome, eg, vaginal discharge. bility of infection in young When a Pap smear is per-
which looked red and Despite your fear that sexually active people and formed (and reported
DR FIONA ROBINSON
swollen. The cervix looked Estelle will not use condoms, proactively offer chlamydia normal) but in the presence
Balmain, NSW
angry and friable, with an it is important that you con- PCR testing. of vaginal/cervical infection,
ectropion, and there was sig- tinue to encourage their use. should the smear be done
Case study nificant contact bleeding. The Sex Workers Outreach General questions for the again (eg, in three months’
ESTELLE, 26, had recently There was no cervical or Project (SWOP), funded by authors time) when the infection has
moved into the area and was adnexal tenderness and no NSW Health, provides a In a patient with break- cleared?
working in a local massage palpable lymph nodes. I per- impossible. Her Pap smear range of health, safety, sup- through bleeding on Depo- If the pathologist has
parlour. She presented to me formed another Pap smear revealed LSIL (CIN 1), so I port and information services Provera or Implanon, (when reported a completely
because of postcoital bleeding, (including ThinPrep), high referred her for a colposcopy. for sex workers. They also pathology has been normal Pap test in this situa-
worsening over the last few vaginal swabs, cervical swabs have counselling and referral excluded) would it be better tion, the test is repeated at
months. and a test for chlamydial Questions for the authors services. For more informa- to give some supplemental the normal two-year screen-
She had been a sex worker PCR. A pregnancy test was In high-risk patients, is there tion visit www.swop.org.au oestrogen or change the reg- ing interval. A Pap test that
for eight years, had a history negative. any evidence to suggest pro- Outside of NSW the imen completely? is reported as ‘negative with
of abnormal Pap smears (CIN We discussed not working phylactic treatment against national peak body is known A short-term prescription inflammation’, should also
1 and 2), numerous colpo- until the results were known, chlamydia is beneficial, and as the Scarlet Alliance; their of ethinyloestradiol can be be repeated at the normal
scopies and a cone biopsy. but she said this was not an if so, what does it comprise? web site is www.scarlet useful, such as three weeks’ two-year screening interval.
Paps had been done irregu- option. After a lengthy chat There is no evidence for the alliance.org.au treatment with any of the However, national guide-
larly, but the last one had about the importance of using usefulness of prophylactic active combined OCPs, to lines indicate that when a
been reported as normal six condoms, I did not feel confi- treatment of chlamydia Should the local public health settle bleeding (provided the Pap test has been reported
months ago. dent this would happen. except in cases of sexual unit become involved in this patient does not have a med- as ‘unsatisfactory’, it should
Other history included Diagnosis of a chlamydial assault. However, in type of situation? ical condition that con- be repeated in 6-12 weeks,
numerous sexually transmit- infection prompted treatment resource-poor countries, a Chlamydia is a notifiable traindicates the use of with correction (if possible)
ted infections over the years with azithromycin for Estelle, syndromic approach is often infection, so the pathology oestrogen). However, there of the problem that resulted
and three terminations. Her but partner tracing was used to treat STIs, ie, treat- laboratory will notify the is no evidence that this treat- in the unsatisfactory smear.

INSTRUCTIONS
How to Treat Quiz Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s) with an X on this form.
Fill in your contact details and return to us by fax or free post.
FAX BACK FREE POST ONLINE
Irregular vaginal bleeding Photocopy form How to Treat quiz www.australiandoctor.com.au/cpd/
— 18 May 2007 and fax to Reply Paid 60416 for immediate feedback
(02) 9422 2844 Chatswood DC NSW 2067

1. Which THREE statements about vaginal THREE elements of Stella’s history could 6. Vivienne, 69, presents with a history of two ❏ a) Cervical ectropion
bleeding are correct? explain her bleeding? days of vaginal spotting last week, which has ❏ b) Cervical carcinoma
❏ a) The normal menstrual cycle length is ❏ a) She has started taking St John’s wort for now resolved. She is generally well, with no ❏ c) Endometrial polyp
21-35 days mild depression past gynaecological history and is not taking ❏ d) Cervicitis
❏ b) During puberty, anovulation can cause ❏ b) She forgot a pill before the episode of HRT. She has not been sexually active for
irregular and heavy bleeding bleeding 15 years and had her last Pap smear at 65, 9. Which THREE statements about
❏ c) All mid-cycle bleeding is abnormal ❏ c) She also takes sodium valproate for which was normal. Which TWO initial investigating irregular vaginal bleeding are
❏ d) Premenstrual spotting may be caused by epilepsy investigations would you arrange for correct?
endometriosis ❏ d) She had an episode of gastroenteritis last Vivienne? ❏ a) Saline infusion sonohysterography is an
month ❏ a) Laparoscopy improved ultrasound technique for assessing
2. Which TWO statements about irregular ❏ b) Pap smear endometrial irregularities
vaginal bleeding are correct? 4. There are no obvious causes for ❏ c) Transvaginal ultrasound ❏ b) A Pap smear may be reported as normal in
❏ a) It is important to investigate all irregular Stella’s bleeding on history or physical ❏ d) Chlamydia PCR test up to 20% of women with cervical
bleeding because a large proportion of examination. She keeps a bleeding diary abnormalities
women with this symptom will have a serious for two more months and reports that 7. Vivienne is worried that the bleeding may ❏ c) If a transvaginal ultrasound shows the
cause bleeding is continuing to occur in the indicate cancer. Which THREE factors in endometrial lining is <5mm in a post-
❏ b) Endometrial cancer becomes a more likely second or third week of active pills. Which Vivienne’s history or examination would menopausal woman, no further investigation
cause in women over 45 TWO investigations would be most indicate an increased risk of endometrial is generally needed unless bleeding persists
❏ c) Most women with chlamydial cervicitis will appropriate? cancer? ❏ d) Women of childbearing age who report
report intermenstrual or postcoital bleeding ❏ a) Saline infusion sonohysterogram ❏ a) Her weight is 96kg having had a period within the past four
❏ d) Irregular bleeding is common during the ❏ b) Chlamydia PCR test ❏ b) She used the combined OCP for 20 years weeks do not require a pregnancy test
first few months of combined oral ❏ c) Pap smear ❏ c) She previously used oestrogen-only HRT
contraceptive pill use ❏ d) HPV DNA test ❏ d) Her age 10. Which TWO statements about chlamydia
cervicitis are correct?
3. Stella, 22, has been taking Microgynon 20 5. Stella’s investigations return normal 8. Brianna, 22, presents with postcoital ❏ a) It is less common in Australia than
for the past two months. She has had no results. Which TWO management options spotting over the last two months. Her gonorrhoeal cervicitis
significant side effects from the pill except would be appropriate at this stage? periods are regular and she has no additional ❏ b) All sexually active women ≤25 who are not
for several days of light vaginal bleeding ❏ a) Immediate referral for colposcopy intermenstrual bleeding. Brianna uses regularly using condoms should be offered
noted last month during the third week of ❏ b) Changing her contraceptive pill to one condoms inconsistently with her current testing for chlamydial infection
active pills. She is in a stable relationship, containing 30µg oestrogen partner of four months. She had a normal ❏ c) Partners of women with chlamydial
had previously used condoms for ❏ c) Stopping the OCP and going back to Pap smear six months ago. From the history cervicitis should be tested and treated if
contraception, had no irregular bleeding condom use for a few months to see if the alone, which TWO causes would you found also to be infected
before starting the Microgynon and had a bleeding continues consider most likely to be causing Brianna’s ❏ d) Azithromycin 1g orally provides adequate
normal Pap smear 21 months ago. Which ❏ d) Change Stella’s pill to Loette postcoital bleeding? treatment for chlamydial cervicitis

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HOW TO TREAT Editor: Dr Marcela Cox
Co-ordinator: Julian McAllan
Quiz: Dr Marcela Cox
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.

NEXT WEEK Adult sexual assault is a distressing and difficult problem. Counselling and a non-judgmental approach are mandatory, and high-quality forensic and medical sexual assault care critical to
successful patient outcomes. The next How to Treat focuses on these medical and forensic aspects of care for adult victims of sexual assault. The authors are Dr Vanita Parekh, staff specialist, Canberra
Sexual Health Centre and forensic and medical sexual assault care, the Canberra Hospital, and Secretary of FAMSAC Australia; and Dr Ronald McCoy, GP, St Kilda, Victoria.

34 | Australian Doctor | 18 May 2007 www.australiandoctor.com.au