Abnormal Uterine Bleeding

Clinical Description

Bleeding which deviates from normal menstrual pattern: interval, duration and amount.

It may be acute or chronic

Note: Episode of heavy bleeding requiring immediate intervention.

Signs and Symptoms

• Prolonged heavy cyclical bleeding, intermenstrual bleeding, cyclical bleeding
• If prolonged or heavy bleeding, may have tachycardia, palpitations, pallor, dizziness and general malaise.

Investigations

• Investigate for PALM-COEIN (Polyps, adenomyosis, leiomyomas, malignancy, coagulopathy, ovulatory dysfunction, endometrial causes, iatrogenic causes, none classified causes)
• Pregnancy test, clotting test

Treatment

• Stabilise (resuscistate) and then definitive management of cause.
• To reduce/stop bleeding
• Give high dose ibuprofen 800mg 8 hourly for5 days
• Give Tranaxemic Acid 1g 8 hourly po for up to 5 days
• Combined oral contraceptive 2 tabs daily for 10days then 1 daily 2-6 cycles unless contraindicated. (For women over 40 years discuss with senior clinician before giving COC)
• Give Ferrous Sulphate 200mg daily for 2-4 weeks or until Hb is normal.

Refer if persistent

• Adolescents, usually physiological, pathology rare
• Exclude pregnancy and its complications and manage conservatively
• If bleeding is heavy manage as above
• Women of childbearing age:
• Strongly suspect complications of pregnancy including ectopic pregnancy. Other causes: use of hormonal contraceptives, DUB, IUCD, fibroids, choriocarcinoma, cervical cancer
• Speculum examination mandatory to rule out local causes

Where no organic cause found

• Give Cyclic Progesterone 5-10mg 12 hourly for 14 days on second part of the cycle; alternatively, oral COC 1 od 3-6 cycles
• If no improvement refer to specialist

Post-menopausal women

• Important causes are endometrial cancer, cervical cancers, cervical polyps, atrophic vaginitis
• Always need investigation therefore refer early

AT THE HOSPITAL

• Speculum examination mandatory
• USS for masses and endometrial thickness. If >4mm, do obtain endometrial sample for histology.