PROLONGED AND HEAVY MENSTRUAL BLEEDING: INVESTIGATIONS

CONTENT

-BLOOD WORK

-IMAGING TECHNIQUES

-ENDOMETRIAL BIOPSY

-HVS AND ENDOCERVICAL SWAB

-PAP SMEAR AND CERVICAL BIOPSY

 

BLOOD WORK

1. FULL BLOOD COUNT

All patients complaining of HMB must have thier full blood count with haematocrit level done to ascertain the presence or absence of anaemia as well as the severity of the anaemia. Other abnormalities in the blood cells that can affect the patient’s health or predispose to bleeding such as platelet’s count must be assessed and corrected.

2. COAGULATION SCREEN

This is a blood test done to assess for deficiencies of any of the important blood factors necessary for normal blood clotting. It is not indicated unless clinical findings from the history suggest a bleeding disorder. Workup and treatment in such a case requires specialists in the field of haematology.

3. HORMONAL ASSAY

A thyroid function test is the only hormonal test relevant in the investigation of HMB and similar to the above, it is only indicated in cases where clinical findings suggest so, otherwise it is not a routine test. Other hormonal profile are only important in the context of irregular or absent menstrual bleeding and not in the investigation of HMB.

4. IMAGING TECHNQUES

1) ULTRASONOGRAPHY

Of all the imaging modalities that can be used to view the abdomen and the pelvis, ultrasonography is the most utilized. It is probably indicated in all cases of HMB and it is more readily available, cheaper and less cumbersome than the other known imaging techniques. An abdominopelvic scan is particularly accurate in identifying the size and location of uterine fibroids in women presenting with clinically obvious abdominal masses. It is also important in assessing the kidneys and ureters for evidence of hydronephrosis and hydroureters due to the pressure effect of huge uterine fibroids on the ureters. Similarly, an abdominopelvic scan may also help to diagnose uterine masses due to adenomyosis. Other lesions that can be seen from an abdominopelvic scan include endometrial cancers and cervical cancers.

Even more importantly, women with no obvious abdominal masses on clinical examination must do a transvaginal scan (TVS) to exclude the presence of endometrial polyps, submucous fibroids, endometrial hyperplasia and endometrial cancer. To improve the accuracy of a TVS for the diagnosis of an endometrial polyp, a saline infusion sonohysterography and or a doppler imaging may be added to routine TVS. Finally, TVS has now become the first line tool for investigating endometrial hyperplasia reducing the need for unnecessary hysteroscopy and endometrial biopsy. Endometrial cancer may also be suspected by the use of a TVS, with its sensitivity enhanced by the use of doppler imaging. CT scan and MRI Scans are rarely indicated unless in cases of suspected adenomyosis or for the assessment of possible abdominal metastasis in suspected or confirmed cases of malignant uterine masses.

2) HYSTEROSCOPY

This refers to an endoscopic view of the inner lining of the uterus. Its frequency has been reduced by the advent of the TVS, but it remains the gold standard for the diagnosis of endometrial polyps allowing for both diagnosis and treatment in the hands of experienced personnel. It can also be combined with endometrial biopsy for women in whom an earlier endometrial biopsy has failed to provide sufficient tissues for histopathologic assessment.

5. ENDOMERIAL BIOPSY

An endometrial biopsy is the process of obtaining samples from the internal lining of the uterus for the purpose of investigating for the presence of malignant and premalignant changes in the womb i.e. to confrim or exclude endometrial cancer and endometrial hyperplasia respectively. It is usually done in the clinic or in a mini theatre using a small plastic tube attached to a device that creates a negative pressure for aspirating or sucking the content of the uterus and the endometrium. It is indicated in all women above 40 years with HMB, or any woman with an increased risk of developing endometrial cancer (e.g. women with longstanding PCOS or those with a family history of a cancer syndrome that includes endometrial cancer e.g. Lynch syndrome) presenting with HMB and in those in whom the medical treatment of DUB has failed.

6. HIGH VAGINAL AND ENDOCERVICAL SWAB

Because PID can cause HMB, an endocervical swab (E/C/S) and a high vaginal swab (H/V/S) should be taken and sent for culture and sensitivity test whenever there is an unusual vaginal discharge reported or observed on examination or whenever there is a history suggestive of PID or in women with an increased risk of PID presenting with HMB.

7. CERVICAL BIOPSY AND SMEAR

Similar to above, whenever a history or cervical examination suggest a cervical cancer, cervical biopsy must be taken and sent for histology. All women who are due for a cervical smear or who have not been screened before should be screened immediately for an abnormal pap smear as part of the campaign against cervical cancer.

 

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