Genital bleeding unrelated to the menstrual period.
In women of childbearing age, always assess if the bleeding is related to a pregnancy.
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.
– In the event of heavy haemorrhage or shock :
• Start an IV infusion of Ringer lactate; monitor vital signs (heart rate, blood pressure);
• Prepare for a possible blood transfusion (determine patient's group, identify potential donors);
• If a transfusion is performed, only use blood that has been screened (HIV, hepatitis B and C, syphilis; malaria in endemic areas).
– In the event of referral to a surgical facility, difficult transport conditions might aggravate the haemorrhage: the patient should have an IV line and be accompanied by family members who are potential blood donors.
– Prevent or treat anaemia (measure haemoglobin if possible).
According to clinical examination
Speculum examination: determine the origin of the bleeding [vagina, cervix, uterinen cavity]; appearance of the cervix; estimation of blood loss;
Bimanual pelvic examination: look for uterine motion tenderness, increased volume or abnormalities of the uterus.
– Friable, hard, ulcerated, hypertrophic mass on the cervix: possible cervical cancer; surgical treatment is required. While waiting for surgery, tranexamic acid PO (1 g 3 times daily for 3 to 5 days) 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, misshapen uterus: uterine fibroids; surgical treatment if large fibroids cause significant bleeding. While waiting for surgery or if surgery is not indicated, treat as a functional uterine bleeding.
– Normal uterus and cervix: possible functional uterine bleeding: tranexamic acid PO as above. In situations of repeated bleeding, it can be combined with an NSAID (ibuprofen PO for 3 to 5 days, see Pain, Chapter 1) and/or a long-term treatment with oral estroprogestogens or injectable progestogens.
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).