Advice for cardiology healthcare professionals: management of abnormal uterine bleeding in women with heart disease
- AUB is a symptom, not a diagnosis. Ultimately, treatments should be targeted to the underlying cause. FIGO AUB system 2 outlines structural and non-structural causes of AUB using the acronym “PALM COEIN.” (Polyps, Adenomyosis, Leiomyoma, Malignancy, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic e.g., apixaban/warfarin, Not otherwise classified; Munro et al., 2018)
- First line treatments to improve symptoms and reduce risk of anaemia can be started while arranging referrals for further investigation to determine cause.
- Inform GPs of any first line treatments that have been commenced and request their consideration of further investigation as per local guidelines (Flowchart for discussing menstrual symptoms, referral and treatment).
- Patients at higher risk of endometrial cancer (as per NICE guidance; NICE, 2018) or on anticoagulants with AUB should be referred directly to gynaecology (Flowchart for discussing menstrual symptoms, referral and treatment).
- Patients with perimenopausal symptoms may wish to discuss the use of hormone replacement therapy (HRT). The use of HRT is not within the scope of this guideline. The British Menopause Society provides a consensus statement on the use of HRT in women after myocardial infarction (HRT after myocardial infarction
) and coronary heart disease (Primary prevention of coronary heart disease in women ).
Flowchart for discussing menstrual symptoms, referral and treatment
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- Concerns reported during routine enquiry to all women of reproductive age: "Do you have any concerns about menstruation or your menstrual blood loss?"
AND/OR
- Incidental finding of low ferritin (<30μg/L) or haemoglobin (<120g/L)
AND/OR
- Reported symptoms suggestive of anaemia.
Yes
- Discuss and document menstrual symptoms and parameters (Menstrual symptoms and normal parameters) (e.g. 9/32, heavy)
- Ensure up to date haemoglobin result available and treat anaemia as per local guidelines.
High risk for endometrial pathology (as per NICE guidelines): persistent intermenstrual or persistent irregular bleeding, women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome, women taking tamoxifen, women for whom treatment for HMB has been unsuccessful.
No
Yes
Inform GP and ask them to consider work up as per local guidelines e.g. pelvic exam +/- cervical smear, STI screen, pelvic ultrasound, FBC and ferritin.
Refer directly to gynaecology via SCI gateway referral to department.
- Provide patient with link to NHS Inform https://www.nhsinform.scot or HOPE website www.ed.ac.uk/hope
- Consider first line treatments as outlined in First line treatment options to reduce risk of anaemia in patients with AUB and heart disease whilst awaiting further investigation.
- First line treatment options summarises considerations in heart disease.
- Inform GP of any treatments commenced.
- Provide patient with link to NHS Inform https://www.nhsinform.scot or HOPE website www.ed.ac.uk/hope
- Consider first line treatments as outlined in First line treatment options to reduce risk of anaemia in patients with AUB and heart disease whilst awaiting further investigation. NB, avoid estrogen containing medication in patients who are waiting referral to gynaecology as they may be high risk for endometrial pathology.
- First line treatment options summarises considerations in heart disease.
- Inform GP of any treatments commenced.