Uterine Bleeding, Abnormal (AUB)

Definition

General measures

Medicine treatment

Referral

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ICD-10 code: N92.0–6

DEFINITION

Abnormal uterine bleeding (AUB) is defined as any symptomatic variation from normal menstruation in terms of regularity, frequency, volume, or duration. AUB can either be acute, i.e. an episode of heavy bleeding of a sufficient volume to require immediate intervention to prevent further blood loss, or chronic, i.e. present for more than 6 months.

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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

The management of AUB due to a pathological condition is aimed at that particular pathology. If no organic cause is found, manage medically as follows:.

Arrest of acute haemorrhage

• Progestin, e.g.:
  • Norethisterone, oral, 5 mg 4 hourly until bleeding stops.
    • Maximum duration of use: 48 hours.

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OR

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

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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

ICD-10 code: N92.6

For women in the reproductive years:

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

OR

Alternative to combined oral contraceptives:
Progestin only:

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

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OR

• Norethisterone, oral, 15 mg 8 hourly from day 5 to day 26 of the cycle.
  • Use for 3–6 cycles.

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OR

• NSAID, oral: e.g.
  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal for 2 to 3 weeks.
    • Begin trial of NSAID starting on 1^st day of menses until menses cease.

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OR

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

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For perimenopausal women, hormone therapy (HT):

ICD-10 code: N92.4

• Conjugated estrogens, oral, 0.625 mg daily for 21 days.

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• Medroxyprogesterone acetate, oral 10 mg daily from day 11 to day 21.
  • Omit treatment from day 22– 28 no treatment.
  • Continue both treatment for 3–6 cycles.

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.

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Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital _Chapter 5: Gynaecology; Version 1.0, 2020-4_June 2024