Abnormal uterine bleeding (in the absence of pregnancy)

Last updated: October 2021

• Heavy menstrual bleeding or intermenstrual genital bleeding
• In women of childbearing age:
  • assess if the bleeding is pregnancy-related;
  • perform a pregnancy test.

For the management of pregnancy-related bleeding, refer to the guide Essential obstetric and newborn care, MSF.

In all events

• Rapidly assess the severity of bleeding.
• Perform a pelvic examination:
  • speculum examination: determine the origin (vagina, cervix, uterine cavity) and cause of the bleeding; appearance of the cervix; amount and intensity of bleeding;
  • bimanual examination: look for cervical motion tenderness, uterine enlargement or irregularity.
• Assess for recent trauma or surgical history.
• Measure haemoglobin, if possible, to prevent or treat anaemia.
• In the event of signs of shock, see Shock, Chapter 1.
• In the event of heavy bleeding:
  • start an IV infusion of Ringer lactate;
  • monitor vital signs (heart rate, blood pressure);
  • administer [1] Citation 1. American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-6. 
    https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-1.pdf :
    tranexamic acid IV: 10 mg/kg (max. 600 mg) every 8 hours. When bleeding has been reduced, switch to tranexamic acid PO: 1 g 3 times daily, until bleeding stops (max. 5 days).
  • if bleeding persists and/or in case or contraindication to tranexamic acid, administer one of the following two drugs (except if suspicion of cervical or endometrial cancer):
    ethinylestradiol/levonorgestrel PO (0.03 mg/0.15 mg tab): one tablet 3 times daily for 7 days
    or medroxyprogesterone acetate PO: 20 mg 3 times daily for 7 days
• In case of massive haemorrhage and/or lack of response to medical management: surgical management (dilation and curettage, intrauterine balloon, and as a last resort, hysterectomy).
• In the event of referral to a surgical facility, difficult transport conditions may aggravate the bleeding: the patient should have an IV line and/or be accompanied by family members who are potential blood donors.
• If available, POCUS a Citation a. POCUS should only be performed and interpreted by trained clinicians. : perform FAST to evaluate for free fluid and/or urological abnormalities; perform pelvic views to evaluate for uterine and/or adnexal pathologies.

According to clinical examination

• Friable, hard, ulcerated, hypertrophic mass on the cervix: possible cervical cancer; surgical treatment, chemotherapy, radiation therapy or palliative care is required depending on the stage of the cancer. While waiting for appropriate treatment, tranexamic acid PO (1 g 3 times daily for 5 days max.) may be used to reduce bleeding.
• Inflammation of the cervix, light or moderate bleeding, purulent cervical discharge, pelvic pain: consider cervicitis (see Abnormal vaginal discharge) or salpingitis (see Upper genital tract infections).
• Enlarged, irregular uterus: uterine fibroids. In case of failure to respond to medical treatment, surgical management is required. While waiting for surgery or if surgery is not indicated, treat as for functional uterine bleeding.
• Normal uterus and cervix: possible functional uterine bleeding: tranexamic acid PO as above. In case of repeated bleeding, it can be combined with an NSAID (ibuprofen PO for 3 to 5 days, see Pain, Chapter 1) and/or one of the following long-term treatments:
  • levonorgestrel intrauterine device
  • or ethinylestradiol/levonorgestrel PO (0.03 mg/0.15 mg tab): one tablet daily
  • or medroxyprogesterone acetate IM: 150 mg every 3 months
  • or medroxyprogesterone acetate PO b Citation b. Unlike the other treatments, this drug has no contraceptive effect. : 10 mg once daily (up to 30 mg once daily if necessary) for 21 days monthly.

Note: rule out other causes of vaginal bleeding before diagnosing functional uterine bleeding. Consider for example poorly tolerated contraceptive, endometrial cancer in postmenopausal women, genitourinary schistosomiasis in endemic areas (see Schistosomiasis, Chapter 6).