Abnormal uterine bleeding (in the absence of pregnancy) — MSF Clinical guidelines

What this guideline says

GMJ summary

This MSF clinical guideline addresses the assessment and management of heavy menstrual bleeding and intermenstrual bleeding in non-pregnant women. The guidance emphasises rapid assessment of bleeding severity, pregnancy exclusion in women of childbearing age, and systematic pelvic examination to determine the origin and cause of bleeding.

For heavy bleeding, the guideline recommends initial management with intravenous tranexamic acid (10 mg/kg, maximum 600 mg every 8 hours), switching to oral tranexamic acid (1 g 3 times daily for maximum 5 days) when bleeding reduces. If bleeding persists or tranexamic acid is contraindicated, hormonal therapy with combined oral contraceptives or medroxyprogesterone acetate is recommended. Massive haemorrhage unresponsive to medical management requires surgical intervention.

The guideline provides specific management pathways based on clinical examination findings, including cervical cancer, cervicitis, uterine fibroids and functional uterine bleeding. For functional uterine bleeding, long-term management options include levonorgestrel intrauterine devices, combined oral contraceptives, or injectable or oral medroxyprogesterone acetate, often combined with NSAIDs for symptom control.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. In women of childbearing age, always exclude pregnancy with a pregnancy test before managing abnormal uterine bleeding
2. For heavy bleeding, administer tranexamic acid IV 10 mg/kg (maximum 600 mg) every 8 hours, then switch to oral tranexamic acid 1 g 3 times daily until bleeding stops (maximum 5 days)
3. If bleeding persists or tranexamic acid is contraindicated (and no suspicion of cervical or endometrial cancer), give ethinylestradiol/levonorgestrel 0.03 mg/0.15 mg one tablet 3 times daily for 7 days or medroxyprogesterone acetate 20 mg 3 times daily for 7 days
4. Perform speculum examination to determine bleeding origin (vagina, cervix, uterine cavity) and bimanual examination to assess for cervical motion tenderness, uterine enlargement or irregularity
5. For functional uterine bleeding with repeated episodes, long-term management includes levonorgestrel intrauterine device, combined oral contraceptives, or medroxyprogesterone acetate IM 150 mg every 3 months
6. Friable, hard, ulcerated or hypertrophic cervical mass suggests cervical cancer requiring surgical treatment, chemotherapy, radiation therapy or palliative care depending on stage
7. In massive haemorrhage or lack of response to medical management, surgical management is required (dilation and curettage, intrauterine balloon, or as last resort hysterectomy)
8. Consider other causes before diagnosing functional bleeding: poorly tolerated contraceptives, endometrial cancer in postmenopausal women, genitourinary schistosomiasis in endemic areas

Management of heavy bleeding according to clinical findings

Table extracted from the guideline

Source: Médecins Sans Frontières, Abnormal uterine bleeding (in the absence of pregnancy) — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“In the event of heavy bleeding: start an IV infusion of Ringer lactate; monitor vital signs (heart rate, blood pressure); administer tranexamic acid IV: 10 mg/kg (max. 600 mg) every 8 hours.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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