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CDHB

Menorrhagia

Heavy vaginal bleeding with negative urinary beta-HCG.

Aetiology

• Dysfunctional uterine bleeding.
• Bleeding secondary to trauma (vaginal laceration/blunt force trauma). Consider abuse and ask about this. If confirmed refer to Doctors for Sexual Abuse Care for advice before examination unless clinical condition renders this unsafe.
• Neoplasia.
• Bleeding disorders.
• AV malformation.

Investigations

• Urinary beta-HCG.
• Speculum examination and check smear status.
• Cervical and vaginal swabs (Chlamydia, Neisseria, high vaginal swab for bacterial vaginosis).
• CBC + diff and iron studies - consider group and hold if bleeding heavy.
• Ultrasound scan of pelvis.
• INR, APTT, fibrinogen. Consider platelet dysfunction, inherited and acquired.
• TFTs if history suggestive.

Management

• IV fluid replacement and resuscitation if necessary.
• Call Gynaecology Registrar.
• Heavy cervical bleeding (e.g., neoplasia, post cervical surgery): consider silver nitrate or Monsel's solution (ferric subsulphate) application. If this fails then tamponade with a vaginal pack pressed closely to cervix and insert a Foley urinary catheter into the uterus. Seek advice from the on-call Gynaecology Registrar before doing this.
• Tranexamic acid 1 g QID PO.
• Norethisterone or medroxyprogesterone 30 mg stat then norethisterone 5 mg TDS or medroxyprogesterone 10 mg BD. All PO.

  Note: Discuss with Gynaecology Registrar before giving high dose progestogens if uterine bleeding and possible risk for neoplasia (hyperplasia can be temporarily histologically corrected by progestogens).

• Infection: treat with broad spectrum antibiotics.
• Polyps require removal and histology.

Topic Code: 35911