Abnormal vaginal bleeding

Question 1

Abnormal Vaginal Bleeding 🩸

Answer 1

Abnormal Vaginal Bleeding
This refers to bleeding which deviates from the normal menstrual pattern (in terms of the amount, duration or interval).

Abnormal menstrual patterns and bleeding are common in young adolescents and women within the ages of 45-50 years.

No cause may be found on investigation in these age groups as it is mostly due to immaturity or ageing of the ovaries and its pituitary controls.

Bleeding may be mild or severe and life threatening.

In other age groups, the causes are multiple and may be associated with the identifiable disorders.

Postmenopausal bleeding is said to occur when a woman who has stopped having menstruation for 6-12 or more months begins to bleed per vagina.

Occasionally bleeding from the rectum and urethra may be confused with genital tract bleeding.

Treatment is directed at the cause found.

Question 2

Causes

Answer 2

Causes
Pre-pubertal girls:
y Urethral mucosal prolapse
y Coital lacerations due to rape and defilement
y Trauma

Young Adolescents:
y Dysfunctional uterine bleeding
y Complications of pregnancy
y Coital lacerations due to rape and defilement
y Accidental traumatic lesions of vulva and vagina

Women of Child Bearing Age:
y Complications of pregnancy, including ectopic pregnancy, abortion
and choriocarcinoma
y Coital lacerations
y Use of hormonal methods of contraception or intrauterine
contraceptive device (IUCD)
y Cervical cancer
y Fibroids
y Dysfunctional bleeding

Peri-menopausal Women:
y Dysfunctional uterine bleeding
y All other causes listed for women of childbearing age also apply

Post-menopausal Women:
y Pelviccancerssuchascervicalcancer,
endometrial cancer,vaginalor
vulva cancer and ovarian tumours
y Withdrawal from oestrogen therapy y Atrophic vaginitis
y Endometritis
y Coital tears
y Urethral caruncle

Question 3

Signs and symptoms

Answer 3

Symptoms
y Vaginal bleeding which deviates from normal menstrual pattern
y May be associated lower abdominal pain or dysmenorrhoea
y Symptoms of anaemia (dizziness, palpitations, easy fatigue etc.)

Signs
y Signs of anaemia (if heavy bleeding) y Other signs related to cause

Question 4

Investigations

Answer 4

Investigations
y FBC
y Sickling test
y Blood clotting screen e.g. Prothrombin time, INR
y Pelvic ultrasound scan (to rule out pelvic lesions)
y Urinalysis
y Diagnostic Dilatation and Curettage (DD & C) for women of child
bearing age and postmenopausal women

Question 5

Treatment

Answer 5

Treatment
Treatment objectives
y To resuscitate patient where necessary
y To find the cause of bleeding
y To treat and stop the bleeding 🩸

Non-pharmacological treatment

y Vaginal coital tear - suturing in theatre
y Inevitable or incomplete abortion - uterine evacuation
y Surgery (myomectomy, hysterectomy, oophorectomy etc.)
y Radiation therapy for cancers

Pharmacological treatment

A. Dysfunctional uterine bleeding – mild bleeding
1st Line Treatment
y Norethisterone acetate, oral, 5 mg 8 hourly for 10-12 days (to stop bleeding)
5 mg 12 hourly (days 19 to 26 of cycle to prevent bleeding)

2nd Line Treatment
y Mefenamic Acid, oral, 500 mg 8 hourly on days 1 to 5 of cycle (Especially if associated with dysmenorrhoea)

B� Life threatening bleeding
1st Line Treatment
y IV fluids and blood transfusion as required
And
y Tranexamic Acid, oral or IV, 1 g 6-8 hourly for 4-7 days

2nd Line Treatment

Evidence Rating: [B]
y Mefenamic Acid, slow IV injection, 500 mg 8 hourly (days 1 to 5 of cycle)
C� For recurrent or protracted abnormal bleeding
1st Line Treatment Evidence Rating [A]
Low dose oral contraceptive pill daily for 3-6 cycles or longer
y Ethinylestradiol + levonorgestrel
Or
y Ethinylestradiol + norethisterone

2nd Line Treatment

Evidence Rating: [C]
y Conjugated oestrogen, oral, 1.25-2.5 mg daily for 10-12 days
And
Evidence Rating: [A]
y Norethisterone, oral, 5-10 mg 8 hourly for 21 days (days 5-25)
Or
Evidence Rating: [B]
y Medroxyprogesterone acetate, oral, 5-10 mg daily for 5-10 days (days 19 to 26 of cycle)

Referral Criteria
Refer all women with heavy menstrual bleeding and/or abnormal vaginal bleeding not responding to therapy to a gynaecologist for comprehensive assessment and management.