see also: [[miscarriage and threatened miscarriage]], [[Ectopic pregnancy]] references: [Dunn - Dysfunctional uterine bleeding](x-devonthink-item://5DA57C56-F9E1-4F40-A899-A5951442BAF2), [Dunn - Abnormal vaginal bleeding](x-devonthink-item://5DA57C56-F9E1-4F40-A899-A5951442BAF2), [Rosen - Vaginal Bleeding](x-devonthink-item://2FBEA310-AF85-4027-880C-88205BA4834E), [Tintinalli - Abnormal uterine bleeding](x-devonthink-item://C90915F0-2F25-44A0-9766-904D24D15648?page=0) links: [LITFL abnormal vaginal bleeding](https://litfl.com/abnormal-vaginal-bleeding/) > [!key points] > - Vaginal bleeding can be **pregnancy-related** or **non-pregnancy related**; This document concerns *non pregnancy related vaginal bleeding* ; see [[miscarriage and threatened miscarriage]] for pregnancy-related bleeding > - ==all women of childbearing age with PV bleeding much be assumed to be pregnant until proven otherwise== > - all **postmenopausal women with PV bleeding must be assumed to have carcinoma** (vaginal, cervical, or endometrial) until proven otherwise # Terminology - _Menorrhagia:_ Menstrual cycles that are either excessive or prolonged - A strict definition of menorrhagia is defined as a loss of more than 80 mL per menstrual cycle (about 6 tampons per day for 4 to 5 days).1 - _Metromenorrhagia:_ Excessive or prolonged bleeding that occurs at irregular intervals. - _Oligomenorrhoea:_ Interval between uterine bleeding from 35 days to 6 months. - _Polymenorrhoea:_ Regular bleeding that occurs at intervals shorter than 21 days. - _Amenorrhoea:_ The absence of bleeding for more than 6 months - _Intermenstrual bleeding:_ Bleeding that occurs between otherwise regular menstrual periods. # PALM-COEIN PALM - structural etiologies COEIN - non-structural etiologies - **Polyps** (endometrial and cervical) - age >35, intermensrual bleeding. USS or hysteroscopy - *Cervical ectropion* (cervical cells on outside of cervix → looks similar to cervical cancer. can be caused by hormonal Δs, OCP, pregnancy. may have non-purulent vaginal discharge, intermentrual bleeding, post-coital bleeding. - **Adenomyosis** - painful heavy periods. age >30, USS or MRI - **Leiomyoma** (aka uterine *fibroids*) - palpable if large, usually asymptomatic. age >30, USS - **Malignancy** and hyperplasia - age >45 or risk factors. need endometrial biopsy - **Coagulopathy** -- eg [[Von Willebrand disease]], cirrhosis, [[thrombocytopaenia]] - **Ovulatory dysfunction** - responds well to hormones - often in extremes of reproductive age - can be due to thyroid disease or pituitary disease (hyperprolactinaemia, gonadotropin ecess) - **PCOS** - **Endometrial** - cyclical menorrhagia without a clear cause - **Iatrogenic** - IUD, retained tampon - Drugs: anticoagulants, chemo, steroids, OCP, HRT, tamoxifen - **N**ot otherwise classified - trauma - AVM - PID, endometritis - vaginal atrophy - liver disease - rapid weight change - renal disease - *vaginal atrophy* # Treatment depends on cause of course 20 mcg Mirena most effective for reducing heavy menstrual bleeding treat [[Anaemia]] if appropriate > [!doses] > - Primolut (norethisterone) 5 mg po > - mefenamic acid 500 mg TDS (or naproxen 250mg TDS or ibuprofen) > - TXA 1g TDS first 3-5 days of menstruation ## menorrhagia associated with ovulatory cycles hormonal mgmt preferred ; can do combined oral contraceptives, oral progestins, or IV estrogen - *norethisterone* 5mg bd or tds - *medroxyprogesterone acetate* 10mg 1-3 times/day on days 1-21 of 28 day cycle side effects area nausea, lethargy, headache, bloating, acne tx <6 months due to risk of hypo-estrogenism *levonorgestrel-releasing intrauterine system* good for heavy menstrual bleeding associated with ovulatory or anovulatory cycles, high patient satisfaction rates, and reduces bleeding more effectively than a 21 day course of norethisterone and avoids systemic effects of oral progestins - [[TXA]] - 1 to 1.5g TDS or QID for first 3-5 days of menstruation - side effects: nausea and leg cramps - active thromboembolic disease is contraindication to use - NSAIDs -- *mefenamic acid* 500mg TDS (or naproxen 250 mg TDS or ibuprofen 400mg TDS) - block PGE2, a vasodilator found in excess in pts with menorrhagia. - helpful if there is associated dysmenorrhoea