Uterine bleeding, abnormal

N92.0–1

GENERAL MEASURES

All women >45 years of age with AUB should have a transvaginal ultrasound and endometrial sampling to exclude pathology.
Actively exclude organic causes, e.g. fibroids, for abnormal uterine bleeding. All women should receive a speculum examination to rule out cervical pathology. A cervical cytology smear should be performed if the cervix appears abnormal or if indicated according to the national screening program.

MEDICINE TREATMENT

Dysfunctional uterine bleeding implies that no organic cause is present.

Arrest of acute haemorrhage

Progestin, e.g.:

LoEIII [4]

  • Norethisterone, oral, 5 mg 4 hourly until bleeding stops up to a maximum 48 hours.

OR

Tranexamic acid, oral, 1g 6 hourly on days 1–4 of the cycle.

LoEI [5]

After bleeding has stopped, continue with:

  • Combined oral contraceptive, oral, 1 tablet 8 hourly for 7 days.
    • Follow with 1 tablet once daily for 3 months.

For restoring cyclicity N92.6

For women in the reproductive years: (Z30.2)

  • Combined oral contraceptive, oral, 1 tablet daily for 6 months.

OR


As alternative to combined oral contraceptives:

Progestin only: (Z30.2)

  • Medroxyprogesterone acetate, oral, 30 mg daily from day 5 to day 26 of the cycle.
    • Use for 3–6 cycles.

LoEIII [6]

OR

  • Norethisterone, oral, 15 mg daily from day 5 to day 26 of the cycle.
    • Use for 3–6 cycles.

OR

  • NSAID, oral: e.g.
  • Ibuprofen, oral, 400 mg 8 hourly with meals.
    • Begin trial of NSAID starting on 1st day of menses until menses cease.

LoEI [7]

OR

  • Tranexamic acid, oral, 1 g 6 hourly on days 1–4 of the cycle.

LoEI [8]

For perimenopausal women, hormone therapy (HT): N92.4

  • Conjugated oestrogens, oral, 0.625 mg daily for 21 days with the addition of medroxyprogesterone acetate, oral 10 mg daily from day 11 to day 21.
    • Day 22– 28 no treatment.
    • Use for 3–6 cycles.

ADD

For dysmenorrhoea and abnormal bleeding:

  • NSAID, oral: e.g:
  • Ibuprofen, oral, 400 mg 8 hourly for 2–3 days with or after a meal, depending on severity of pain.

REFERRAL

Treatment failure - refer for consideration of levonorgestrel intrauterine system or surgical procedures as dictated by the diagnosis.