QuestionSBA
QuestionChoice
The subdermal implant appears to have been in situ for less than three years, therefore does not require replacement unless requested by the patient. Whilst irregular bleeding can occur with the implant, it is rarely a reason for early replacement.
49874
c
Replace her subdermal contraceptive implant
QuestionChoice
Whilst chlamydia infection is common in this age group, a swab should be obtained for NAAT/PCR testing first rather than blindly treating.
49876
e
Treat empirically for chlamydia infection with doxycycline 200mg twice daily for one week
QuestionChoice
While this is a valid option for managing irregular bleeding with progestogen-only contraception, STIs should be ruled out first.
49875
d
Commence a combined oral contraceptive pill to regulate bleeding
QuestionChoice
One of the most common causes of irregular menstrual bleeding in people under the age of 25 is sexually transmitted infections (STI) such as chlamydia. Whilst the implant can cause irregular bleeding, it is important to rule out STIs.
49872
a
Ask her to do a self-obtained lower vaginal swab for chlamydia and gonorrhoea
QuestionChoice
Whilst the implant can cause irregular bleeding, it is important to rule out STIs.
49873
b
Reassure her this is a known side effect of the contraceptive implant and does not require any investigation. She should return at three years to have the implant replaced
Concept
Chapter
# Summary
  
Irregular menstrual bleeding, which could be physiological or due to an underlying condition, is a common gynaecological presenting complaint. Key signs and symptoms include abnormal bleeding patterns, which can be confirmed through pelvic examination, pregnancy test, ultrasounds, and cervical or endometrial biopsy as required. Management strategies primarily involve hormonal treatments such as the combined oral contraceptive pill, Mirena® intrauterine system, norethisterone, and progestogens, provided there is no underlying pathology.
  
 
# Definition
  
 
Irregular menstrual bleeding refers to timings between each menstrual cycle (or period) that are less than 21 days or over 35 days. This condition is common, particularly following menarche, when periods can take 2-3 years to regularise, and when approaching menopause, however, it can also be due to underlying pathology. 
  
 
# Epidemiology
  
 
While irregular menstrual bleeding is common in the general population, it is particularly prevalent among females around the time of menarche and menopause due to the physiological changes occurring during these periods.
  
 
# Aetiology
  
 
The causes of irregular menstrual bleeding can include:
  
 
  - Physiological changes, such as menarche or menopause
  - Polycystic ovarian syndrome 
  - Genitourinary infection, e.g., chlamydia
  - Endometrial hyperplasia
  - Endometrial or cervical cancer
  - Fibroids
  - Pregnancy
  
 
# Signs and Symptoms
  
 
The primary sign of irregular menstrual bleeding is an abnormal bleeding pattern, which may include heavy, prolonged, or frequent periods, or bleeding between periods.

Women aged over 40 with persistent intermenstrual bleeding, new onset menorrhagia and/or severe anaemia (secondary to vaginal bleeding) should be referred to gynaecology and seen within 30 days for suspicion of possible endometrial malignancy.
 
Women with post-menopausal bleeding should be referred to gynaecology under a 2-week wait referral to investigate possible endometrial malignancy. 
 
# Differential Diagnosis
  
The differential diagnoses for irregular menstrual bleeding include:
  
 - **Polycystic ovarian syndrome:** May also have signs of hyperandrogenism (e.g. hirsutism) and insulin resistance. 
 - **Genitourinary infection:** May present with symptoms like lower abdominal pain, dysuria, or unusual vaginal discharge.
 - **Endometrial hyperplasia/cancer:** May show symptoms like pelvic pain, weight loss, or postmenopausal bleeding.
 - **Cervical cancer:** Possible symptoms include abnormal vaginal bleeding, pelvic pain, or pain during intercourse.
 - **Fibroids:** Symptoms may include heavy menstrual bleeding, prolonged menstrual periods, pelvic pressure or pain, frequent urination, difficulty emptying the bladder, constipation, and backache or leg pains.
 - **Pregnancy:** Symptoms may include missed periods, nausea or vomiting, increased urination, and breast tenderness.
  
 
# Investigations
  
 
Investigations to confirm the cause of irregular menstrual bleeding may include:
  
**Bedside:**

  - Pelvic examination, including speculum examination +/- cervical smear if overdue. 
  - Pregnancy test 

**Bloods:**

- FSH levels, especially if suspecting menopause. 
- LH/FSH ratio, if suspecting PCOS. 
- Oestrogen, progesterone levels 
- Testosterone levels 

**Imaging:**
 
  - Pelvic ultrasound, particularly if examination findings suggest conditions like fibroids. 

**Invasive tests:**

  - Cervical biopsy, if cervical smear is abnormal +/- abnormal findings on examination
  - Endometrial biopsy, if endometrial pathology is suspected
  
 
# Management
  
 
The primary management strategies for irregular menstrual bleeding, provided that investigations rule out any underlying pathology, include:
  
 
  - The combined oral contraceptive pill: This can regulate the menstrual cycle.
  - Mirena® intrauterine system: This can reduce overall bleeding.
  - Norethisterone: This is taken on cycle days 5-26 to prevent bleeding.
  - Progestogens, e.g., medroxyprogesterone acetate: This can induce amenorrhoea but cannot be used long term.

If an underlying cause is found, the focus of management should be treating that condition. 


# References

[RCOG Guidelines for abnormal uterine bleeding](https://www.rcog.org.uk/media/oxyfyvy0/2020-05-21-joint-rcog-bsge-bgcs-guidance-for-management-of-abnormal-ute.pdf)

[NHS UK - Irregular periods](https://www.nhs.uk/conditions/irregular-periods/)

[GP Notebook](https://gpnotebook.com/en-GB/pages/gynaecology/referral-criteria-from-primary-care-abnormal-uterine-bleeding)
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Irregular Menstrual bleeding
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Gynaecology
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10011
A 17-year-old female attends the drop-in clinic at her local sexual health clinic with irregular menstrual bleeding.

She has a progestogen-only subdermal implant in situ for contraception, inserted when she was 16. She was initially entirely amenorrhoeic with the implant, however in the past six months has had irregular bleeding, occurring every 4-7 weeks and lasting for 2-9 days.

What is the most appropriate management plan?
a