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Introduction to abnormal uterine bleeding

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The RCOG recommends that hospitals provide a dedicated one-stop menstrual disorder clinic. Similarly, the UK Department of Health recommends hospitals provide a rapid access clinic to enable specialist review of suspected gynaecological cancer pathology within 2 weeks of general practitioner (GP) referral.

Ideally, both clinics should have facilities for outpatient diagnostic gynaecology, including hysteroscopy, colposcopy and pelvic ultrasound. Given the overlapping skill sets, it seems likely that in the future such clinic services could be offered in a combined one-stop menstrual disorder clinic, with some services led by specialist nurses. Such an approach would help to achieve NHS operational ‘referral to treatment’ standards (62 days for urgent GP referrals and 126 days for non-urgent GP referrals) and has potential to achieve NHS cost savings.

This tutorial provides you with comprehensive, up to date and evidence-based information on how to manage women with abnormal uterine bleeding (AUB) and how to deliver an effective one-stop menstrual disorder clinical service.

The learning objectives for this eTutorial are based on the RCOG Core training curriculum module 13: Gynaecological problems.

Learning objectives

By the end of this tutorial you will be able to:

Knowledge

  • Demonstrate knowledge of AUB terminology and FIGO classification system (PALM-COEIN) for causes of AUB
  • Understand the risks and benefits of treatment options for AUB, caused by:
    • polyps of endometrium
    • adenomyosis
    • leiomyoma
    • endometrial hyperplasia
    • coagulopathy
    • combined ovulatory and/or endometrial causes
    • Asherman’s syndrome
    • uterine arteriovenous malformations

Clinical competency

  • Recognise ‘red flag’ features requiring secondary care referral, including: standards for referral-to-treatment in RAC, referral to MDM and/or additional imaging techniques (e.g. MRI) for complex cases (e.g. multiple uterine fibroids, suspected malignancy)
  • Understand the principles of uterine and endometrial assessment using pelvic ultrasound, endometrial biopsy and hysteroscopy and the indications for using other imaging modalities in selected groups
  • Understand hierarchical three-step treatment approach for HMB (NICE CG44 Heavy menstrual bleeding, 2007).
  • Understand the risks and benefits of: operative hysteroscopic procedures, endometrial ablation, uterine artery embolisation and MRI-guided focused ultrasound ablation

Professional skills and attitudes

  • Demonstrate the ability to counsel women on treatment options and be able to explain the nature, risks and benefits of medical and surgical treatments
  • Recognise the need for appropriate referral for more complex cases for detailed evaluation
  • Demonstrate and understand appropriate referral pathways and local protocols if AUB or abnormal findings are identified

Related topics may be found in other StratOG core training eTutorials.

Gynaecological problems:

Surgical procedures:

Last updated:01/08/11 (tutorial revised and updated by Mr Rajesh Varma)

22/01/10 (Saline infusion sonography image replaced with new, higher quality versions)

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