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this life. Thank you very much. Devia. And would you like to put your slides up? Doctor Lee? Yeah. Uh huh. Um, have you tried presenting now with the button in the air. Oh. Okay. Um, just with me. Where is, uh, yeah, sorry. Now, Thank you. And then you can see now. Okay, on. Do you need it to be like this? Is this okay? That's perfect. Thank you. Amazing. Thank you. Can I ask if, um, if the audience confuse the slights, please? Thank you very much. Looking good. Are we good medical? So good up. Good evening, everyone. So we've got Doctor. I leave about one off the GP trainees in, uh, Southwest seven. Um, she'll be talking about heavy menstrual bleeding on, but if you've got any questions, feel free to put it in the chart and she'll read it through during the session. We want to keep it for the end. That's fine as well. On, we'll give Doctor Lee the stage. Thank you. Hello. Good evening, everyone. Um, so I'm here basically to discuss that the heavy menstrual bleeding and there are loads to say Please feel free to ask questions. And also there will be some clinical scenarios as we go through cerebelli. Try as as much as possible to participate in this, um, so heavy minister bleeding. So basically heavy menstrual bleeding is, ah, part off wider spectrum, which is the abnormally trying bleeding. It's defined as any unusual or heavy bleeding from their uterus, and it's the abnormally trying. Bleeding is an umbrella term, so it include the heavy ministry bleeding, the interministerial bleeding on the postcoital bleeding, and as we go through, there will be more details about each one. So our main focus today is the heavy minister bleeding, and it can be really difficult to define the heavy minister bleeding. Do two different perception off. What could be the normal ministrations Be the onto shin and cultural believe, and this is why it is really subjective. You might find in all the literature that defined as more than 60 or more than 80 Mel, but as a matter of fact, it's very hard to measure it on. The definition doesn't depend on measurement. So what? What is the nice standing us about this nice defined mineral Asia as excessive or heavy minister Blood loss, which okays regularly every 24 to 35 days and interfere with a woman's physical, emotional, social on material quality of life. So, um, we will be talking a lot about Sally. So she's our patient today. She's 27 years old. Female patient, she seeing her GP because she's concerned about her, period, so she would come and say, um, doctor, I'm really struggling with how heavy my periods are. So this is the first interactive question. What would you like to ask next? So please put your answers on the chat, and I will be following this in the suggestion how long it has Dean duration of the heavy Peterson days. Right. Um, how long this has been going for. Okay. How long pain. Well done. What's the color? Um, Symptoms of anemia, pain, symptoms of anemia to determine stability and cloths. Anything else that you can think of Any other diseases? How heavy type of product use? How many per day? Um, is this normal for hair? Any post coital. And so Minister bleeding. Has it been always like this? How many paths? Okay, amazing. I think you've done brilliantly in this one, so let's look at that. Um, second slide. So in heavy minister bleeding, history is one of the main diagnostic tools. So in any consultation, we start the consultation with open question. And then you moved gradually to close the question that came to rule in or rule out certain concerns. So you will start by saying, Take me more. Um so, some colleagues answered, Is it's regular or irregular and copper Are you deal done all of this, Thank you very much. So tell me more about their periods, what they are normally like on a while. You do you think this one is different and then you ask about the severity of the symptoms, how there's no scientifically validated scoring, and as I've said, we don't tend to measure it, but you need to explore this in the situation. So, um, number of pads, temples used every day. If she's getting up in the night to change it, this might be telling that it's really heavy, including the bed passing, blood, clothes, symptoms of iron deficiency, anemia. And then you ask here, How's this affecting her life? And this is considered the nice quality standards, so salad will answer. At this point, I cannot even leave the house for the first two days, and I cannot afford to be taken so much time off work. So top 10 do not measure the bleeding. Ask what's how this affecting her life. If it's a bother, it's worth doing something about it. So on. One would think, Why you still asking about the number of pads while you are trying to estimate the severity? Because it will give you a clearer idea and it will give you, um, a way to monitor the situation. For example, I started treatment, and she used to, uh, change six Pataday. And with the treatment, it's coming down to three Pataday. So it's a way to to give a rough estimate about the response off the treatment. But if it's bothering here, we need to do something. So another interactive question. What further question would you like to ask? I think some added this already. Eso Shall we move into them? Answer. So basically you, we we need to get a very detailed on estra history. Minarti. When was the last period Are the cycle regular on what? What's the length of the cycle? And for every bit it has a significance on, but we will need to ask about the usual pretty ministro symptoms. So when you get when you get this heavy period, are they similar to your regular period? You get your usual symptoms. Do you recognize it as a period, or does it come without any warning sign? So ask her if she get bloating. Pelvic pain, sore breasts, mood change These every woman has some, um, group of symptoms that she would be able to recognize. Okay, this is my periods. The reason why we're asking this question. Because if the heavy period came without the usual warning symptoms, this smile be telling us, this is a nerve, you a tree bleeding. And this is particularly common in the extremes of very productive life, like towards menarche or more towards the menopause. Uh, we ask about any enter ministry bleeding that's leading between the periods postcoital bleeding that's bleeding after sex, postmenopausal. So it's important to ask hair. Have you been missing your period over the last year? And then you had an episode of bleeding that you consider the period if there's pain, if there's long breaks between periods because this way she she might fit in oligomenorrhea, which might do to, um, polycystic ovary syndrome. So Sally is standing us. I started my period when I was 13. They have been regular, like clockwork. I read every 28 days, the last for six days. The first day of my last period was seven days ago. They are not particularly painful on. I have. I haven't had any other bleeding. So basically, we're not concerned here about the regularity of the cycles. She doesn't have so far. Any associated sentence, what else would you like to ask? Sally, Um, can you please put your answer on the chapped? What else? We know now? Everything about his periods. Would you like to ask something else about Sally Thyroid's. Okay. Symptoms of sight or disease? Anything else? Would she like to try medication? Any other? Just any post mitral history. Like leading solders. Well done. Anything else? ST I will done the ideas. She sexually active diet and fluid intake normal. Okay, But I'm not clear how this relevant because you might think the dart include intake might. If you mean that, it's it's related to her. Be my so BMR. Usually extreme. Be my mike Lee to immunoreactive other than heavy minister bleeding. I don't know if this is what you mean history of previous pregnancy topic or miscarriage. Okay, so let's move the slide with the answer. So, basically, you will tailor the history in this way to our to rule and rule out any underlying pathology on to be able to tell her the pathology we need to learn what could be the underlying pathology. So very assuring thing that more than 50% of women with Heavy Minister brilliant they will have no identifiable you uterine pathology on. But the feet go, which is the International Federation of Gynecology Obstetrics. They have come up with a kind of classifications system that should help the clinician toe think about it and put it into categories. So basically, it's either structural or non structural causes of abnormally trying bleeding on the supplies as well. Too heavy ministry bleeding. So in this picture, you will see it back. I I personally think off that, and I told me Kelly So what's the uterus is about? It's a lining and the lining is in. Dmitri, um on the individual could give rise to a gross that could be benign. This is polyp or could be malignancy on. Then after the endometrium, you will have the myometrium on the my medium could grow a benign growth. This is the Leo Myoma or also known as by Brian it or if there are some bits of the endometrium embedded inside the myometrium. This is the addendum. I OSIs Onda On the right, you will find the non structure and causes which could be cardiomyopathy. For example, Bone will bring disease ovulatory and example for that will be polycystic ovary. And in Dmitri in any other individual problem that not necessarily a polyp yet. So cardiogenic like, um, the cover are you see, someone mentioned it in the in the chat. It could be responsible for heavy bleeding or not otherwise classified. So basically, we'll ask about if she has pressure symptoms. This could be pointing to large fibroids, pelvic pain, or this one area which could point to add, you know, my OSIs or the presence off sub mucous fibroid. Enter minister bleeding suggest the problem with the endometrium or submucous fibroid sexual activity. You mentioned that quite right on why you ask about sexual activity because you need to consider the pregnancy to exclude it. With any woman presenting with a period of normality, you need to execute pregnancy and mainly topic pregnancy. Um, contraception. You need to ask about the current on the past contraception. Why? Because some of the contraception could be responsible for this bleeding as we mentioned the copper Korean on also hair future plan because when you offer treatment, some treatment will be will have a contraceptive, um, mode of action as well, and some will not. So and you need to ask about survival smears, check of the are known man up to date and any other gynecological problems if she knows about it, like in Demetrio sis on polycystic ovary syndrome. And now Sally Answered, answered our question, saying, I'm married to my husband off three years. I'm sexually active and I haven't had any other partners since I was married. I have never been treated for ST I. I stopped using the pill about six months ago because we are trying for a baby. I had my first smear at age of 25 2 years ago on it was normal. I haven't had the letter from for my next smear yet I have no problems with my water works, and then you continue as you mentioned. Ask about the medical history. Call more predators. Symptoms of anemia. Um, coagulation problem. Hairy dietary cancer Lynch syndrome. This is when you have, um, a genetic reason for the cancer, and it's usually association between a colorectal and endometrial cancer drug history like it's 30 previous treatment for minor Asia and tamoxifen. So tamoxifen is a medication that's sometimes used for breast cancer on it does have an effect on the intermittent, um, so it could be responsible for, um, abnormal bleeding on. Don't forget to ask about the social history. So when we mentioned social history, it's not only there smoking and the alcohol, it's important to make every contact with any woman an opportunity to check your home situation where the hose does she live with? And if she has a part in that, is he supportive? Because sometime women calm presenting with symptoms and actually what stepped here over the edge would be that the partner is not supportive or she's experiencing a domestic violence. So it's important to check the bag rounds of things um, keep in mind that it's lax. What's the ghost under the bed In this situation, mainly in the material cancer, it's important to reassure women that most of the time it's either there isn't any cause or it's benign causes. But however the remain word about sinister causes. So where you would be concerned when increasing age or obesity being my more than 35? Any condition that will you? That because estrogen excess or unopposed estrogen, which will be including in advertised off estrogen only hitch 30. So regarding hit 30 the guidance would say that any woman with a uterus we will give her two hormones so many the estrogen because this is the main thing that will help with the postmenopausal symptoms, and we add the progesterone we call this indomitable protection. So one would think if the woman has already a uterus, she will never be on single hormone or only estrogen Onley. It does happen as usually in a row, like she's been on estrogen on um arena as a source of progesterone for individual protection, and for some reason that was removed on the heck 30 was not amended to be combined. Polycystic ovary syndrome with chronic and of you, a shin insulin resistance. Tamoxifen Use all of this. Will give an excess estrogen that will be constantly stimulating the endometrium and could result in individual hyperplasia, which can be a precursor for into meter cancer. Um, I'm just checking the chat if there are any questions. Okay. A question so far, Socially the back door saying I don't feel particularly tired. My weight hasn't changed. I haven't had any fevers or night sweats, which could be red flags for cancer. I wouldn't say on particularly sensitive to the cold. And this is, um, asking about the thyroid. Um, um, otherwise statin. Well, almost on any medication. I have no allergies. My family are Well, I don't smoke or drink alcohol. So the next question will be what would? What's the next step? Would you like to examine Sally? If you'd like to examine her. Ah, what kind of examination will be doing? Would you please answer in the chat books, any physician blood test, ultrasound appointment and examination, and speak alone anything else? Okay. So, as a matter of fact, in this situation, we do not need to examine Sally. So not everyone presenting with heavy minister bleeding will need an exact as speaker. Um, examination. She has a history of his heavy ministry bleeding with other symptoms. Then you need to offer a physical examination. But and this is why history is one of the main diagnostic tools because you have to go over and over and over again in very detailed a particulate away. So you are pretty sure that it's only isolated heavy menstrual bleeding with no other concerns that will necessary examination. So this is an algorithm, um, that will simplify things. So for any for any woman presenting with heavy minister bleeding after excluding pregnancy ST I any concerns about her survivalist? Mere. If you look on the left side, if she doesn't have abnormal bleeding better if she doesn't have risk factors. If she didn't have previous treatment for this problem before, you don't need to examine. You can treat after checking her full blood count while on the right side. If she have any reason for pelvic pressure symptoms, urinary frequency, then you need to examine on a range for a scan. So a scan is not a must was very important to think about, because if you think about the, um, excessive war clothes on the scanning service. It makes a huge difference to three hours of this patient's. So But what if Sally had interministerial bleeding? The nice will say people with heavy menstrual bleeding suspected sub mucous fibroid polyp on intermittent pathology are offered outpatient hysteroscopy. So this is one situation where you it's not necessarily that you're dangerous. Can you can repair here straight away on the gynie team will arrange for outpatient hysteroscopy What happened in terms off organization of the service. Usually the hospitals will have kind of one stop clinic for the heavy bleeding. So the patient come and there is an outpatient hysteroscopy so they can do with the Andi can do some minors treatments and they sorted in, usually one appointment. So now let's back. Let's get back to Sally. Sally, we are not concerned about Sally Onda. Uh, we decided that we're not examining here because there are no concerns. So what's next? So pregnancy test? Full blood counts. Do we need to investigate for thyroid? Actually, we will do it only if there are clinical concerns about him. Now Sally has a negative urine pregnancy test. Her hemoglobin is 12. She didn't drop her hemoglobin from the previous baseline, so she's not anemic at the moment. Um, on then we think about the management. So basically, when she adding this patient, some will be treated in the primary care. Some will need a referral to the gynie service in the hospital. So regarding the treat regarding the referral, um, this is an interactive question. So if it please put them, um, answer on the chat books. If we have a patient who had a new onset, put me on with the bleeding, she's 52 years old. Um, do you think she needs a referral, and if so, which service? Can you please put them answer on the chat in books? Amazing. So the 52 years old she needs the two weeks weight. It's the cancer both way. Well done. And then see the next patient. So she has heavy ministry bleeding. She's 45. Give her medical treatment for three months on. There is no response. The sheath at the funeral and if so, which service on by which service, I mean, doesn't need to be the two weeks wait or just a referral to the garden out Patient routinely fatal for gyny. Well, dumb, Thank you very much. Now. Treatment options in primary care. So there are some decision A that you can use. You will find it online. Um, I put one of them in the resources as well. It was the end of this presentation. Um, basically, the options is either you do nothing expecting treatment nonhormonal, which will include Ministro Idol or tranexamic acid hormonal, which will include the marina or dual hormones combined contraception or single hormones, which is progesterone in and surgical. Um, so let's let's get back to Sally. What treatment option would be appropriate for Sally? Pleased with the answer on the chat in books. Now, to remind you, Sally is 27 years old. Fat on? Well, her periods are regular. Her be my is normal. We don't have any red flags about hair on do. Um, she didn't try any treatment before. So, off these options, what would you like to advice here on? Remember, she's trying for a baby as well. Okay, amazing. I see some right answers coming. Okay. Well done. Um, it's tranexamic acid. It's so tranexamic acid that those is 1 g TDs. It can be up to Q. D s. And this is different from what said in the package, but it stays. That was advised by the nice. You start on the first day off the period for 4 to 5 days, and it's able to achieve sixties to 75 production off them. Ministry of Blood loss So it's a significant can be a significant improvement on. Now. Let's do some clinical scenarios. So this 26 years old woman, she's coming with heavy periods. They are painful as well. Um, the period lost 46 days. Severe cramping pain for the first three days. She doesn't want to be on contraception as she's getting married shortly on plans to start a family for blood count performed. And it's normal. What would be the most appropriate first line treatment? What would you please with the answer on the Okay, I'm getting six. An emergency six Sinemet acid. Okay. Amazing. Anything else that you can think off? Not for morning. Well done. Yeah, not a steroid, then. Okay. Uh, so well done. You've got to try it when him have a ministry bleeding coexist with this menorrhea. Then the non steroid that should be prepared to tranexamic acid. It's already there's something very simple that she can get over the counter like ibuprofen or may finanical acid as you mentioned 500 mg TVs regular they use of the non steroidal or tranexamic as it should be stubbed if they do not improve symptoms within three months on at that time, you need to refer the patient to the guy in the service if you're seeing the patient than primary care. Another scenario. 46 years old woman. She has three years history off worsening heavy minister bleeding with regular cycles. And this menorrhea She's part of three and she has been sterilized. So we're not concerned here about contraception. She has tried, um, the combined oral pills. She has tried tranexamic acid on within an acid in the past without success. She's not anemic. Your cervical smear is normal on. Obviously, if you have tried all of this, um, she had a pelvic ultrasound on she It doesn't show in you try and abnormalities. We have done in the meter biopsy as well, and it's normal. What? Would you advice this patient? Okay. Uh huh. Um, she has tried combined pills before. So when you say hormonal, what do you mean by her? Morning. I'm getting some nice answers here. Okay. We'll combine the other contraceptive is one of the hormone in is one of the homeowner lines. If you go back to the so hormonal, it's either Marina. They want hormonal, which is the combined or single hormone, which is the progesterone. Okay, surgical options, surgical options. Okay, great. Um, actually, you've got most of the answer, right? So we can suggest hormonal. But when we say hormonal, we will not go back to the combined because we try that. So we need either psychological progestin in the northeast ear in order. Marina Surgical. You're quite right about that individual ablation or hysterectomy. But also, we need to think we can consider expectant, because if you think about it, this has been the situation for three years. We excluded them red flags. We know that we're not concerned about intermitted problem because the biopsy was normal. The scan was normal. She's 46. She might be approaching the menopause. The median age off menopause in the UK is 51. But again, this is very variable from one woman to another. So it might be worth checking her menopausal symptoms on discussed this one here that if she had if she started to experience menopausal symptom and it's expected that menopause, which is the complete cure, is eminent and she would like to avoid surgical treatment. It's an option. And again, um, we give all the option. We give that this option to patient pools and courts, and she has to make the decision. But it has to be an informed decision. Another clinical scenario. 34 years old woman part of three. Present with menorrhagia. Her cycles are regular know particularly painful. No plans for future pregnancy. And she's requesting a long term contraception. Her smears are normal, and up to date she doesn't have interministerial bleeding or postcoital bleeding. Her BMR is normal. What would you advise him? Amazing. I'll get to this question. Um, Stephanie, in a minute. Any other answers for this clinical scenario? Okay, Amazing. Right. That combined a little contraception pills. When you say a long term contraception, we usually the patient needs something that doesn't take daily effort. So basically we think about either the oil or the injection or the implant. This is usually what spent by the long term contraception. However, I'm acknowledging that them, um or pills is not a wrong answer. It just if she's willing to do that Depo injection. Okay, Amazing. I think you've got to try it. So basically, one of the best situation here would be the Mirena, because it will be, uh okay. Yes, I agree. That other option can be used, but, um, usually the marina doesn't You don't need to, like with the day, but you will need to give it every three months, but then the marina, you can put it on, leave it for five years, but And also, um, but yeah, your question. Right. Uh, okay. Now I'm getting to the question with Stephanie. So the question is, can you can we use the continuous progesterone to stop the periods completely or doesn't need to be cycle? The advice with the from the Nice is with is psychological. Um on. I mean, we can you will you will use the progestin continuous if you are using, get for contraception. Right. You are using syrah that because it can sometimes reduce the Ministry of blood loss. But for the sake if you're using it solely for the sake of heaviness or bleeding than the advice so far is by using it, um, for some better off the cycle. And then she stopped that you get withdrawal bleeding, which is period, that will be That won't be heavy. Hopefully and then restart again. This is advised from the Nice Ah, Now, before I moved to the distillery any any other question regarding the heavy minister bleeding. Okay, let's move toe this menorrhea. So this is Arab Breathe grams on this menorrhea. So basically it's painful cramps on D. With the periods on, it can be primary or secondary. So basically crime when you are first faced by patient who is presenting by this menorrhea primary or secondary is kind of fret respective diagnosis because you will make it Onley when you investigated the patient. And you know that if there is no identifiable underlying pelvic pathology would call it at them at this time Primary dysmenorrhea. But then, if you are suspecting or confirming underlying pelvic pathology, this is secondary dysmenorrhea on. Then what could be possibly underlying pelvic pathology in the materials is fibroid Be I d or the presence off coil. What could be the clinical features indicating a serious second recourse off this menorrhea? And this is basically a scientist or pelvic or pelvic or abdominal mass, where it's clear that this is not due to your trying fibroid, and then you will worry that this mass might be very intelligence. You, for example, um, abnormal survive cervix on examination resistant internasal or post courted reading without associated features off the I D, such as pelvic pain, deep dyspareunia, abnormal vaginal or cervical discharge for primary dysmenorrhea. So the main rationale for that this memory is to exclude causes that can be treatable or that can be sinister. Once you excluded that, it's basically pains to give her the pain medication that honesty Rydell she doesn't wish to conceive. You can give him hormonal contraception as an alternative first line, and it gives her the advantage off Interception, um, hate patch or halt both water bottle. If the symptoms are severe and she's not responding to initial treatment, then unitary fair here. But this is something that basically would be treated primarily in the primary care secondary dysmenorrhea. So basically the treatment will be directed towards treating the underlying pathology, So this is likely to happen in the secondary care. So these are the resources that you can use. So basically, it's a the nice guideline for the heavy menstrual bleeding on. They haven't, um, on, um, decision a day as well that you can use. It's very long. So I suggested that if you are using get you send the link or printed, give it to the patient and then she'll need to think about to treat that on, then have further discussion. Ah, there is a one that's might be more concise. I put it here in the resources, or so there's nice guidance for the kind of a logical cancer and went to refill their on their is nice clinical knowledge about this memory. Um, thank you so much on dial hunger. I'll still be here to answer any question. So please feel free either to put it on the chat or toe open your microphone and have any discussion that should like, I think it looks like we don't have any questions of there's any questions in the books. If not, thank you very much. Doctor. Leave about on diffuse the thank you and you can do it. Thank you everyone. Take care. I thank you. Bye.