===== Vaginal Bleeding=====

====Menorrhagia====
//**Preferred term is Heavy Menstrual Bleeding (HMB)**//\\  
Excessive flow and duration at regular intervals (vs Metrorrhagia = irregular bleeding)
  *1st need to establish pregnant vs non-pregnant

  *The goal of the work-up is to determine whether there is a uterine/endometrial abnormality, a disorder of ovulation, or a disorder of coagulation
  *//**The International Federation of Gynaecology and Obstetrics**// developed a mnemonic for these disorders: **PALM-COEIN**
    * //**P**// olyp; //**A**// denomyosis; //**L**// eiomyoma; //**M**// alignancy and hyperplasia
    * //**C**// oagulopathy 
    * //**O**// vulatory dysfunction
    * //**E**// ndometrial
    * //**I**// atrogenic
    * //**N**// ot yet classified)
\\  
==History should then be focused on:==
^Pelvic pain/pathology  |• fibroids, malignancy\\ • [[wiki:gynaecology:Polycystic Ovary Syndrome]] |
^Contraceptive use  |•  |
^Endocrine causes|• pituitary tumour - Galactorrhea\\ • adrenal - Hirsutism\\  • Thyroid disease  |
^Systemic illnesses  |• renal, hepatic  |
^Bleeding disorders  |• Duration of menses ≥7/7, impairment of daily duties\\  • History of Rx for anaemia\\  • FHx of bleeding disorder\\  • Excessive bleeding with tooth extraction, other surgery etc\\  • Family Hx  |
^Medications  |• hormones or anticoagulants  |
^Any past procedures  |• including unsuccessful hormone manipulations  |

==Examination should focus on:==
  *signs of volume loss is priority
  *signs of bleeding diathesis
  *signs of endocrine disorder
  *abdominal and pelvic masses
  *VE for signs of infection or mass

===Acute Management===
  *Fluid resuscitation
  *addressing contributing illnesses and correctable factors - bleeding disorders, anti-coag med's etc
  *Investigation - routine bloods, TFT, prolactin (+/- LH, FSH and adrenal test), coag's, Fe then others depending on background. USS

^NSAIDs  |• evidence for increased local inflammation with increased menstrual blood loss (increased TNF and COX-2)\\ • Mefenamic acid most commonly used. Said to reduce blood loss by ~25%\\ • Other NSAIDs also useful  |
^Tranexamic acid (TXA)  |• anti-fibrinolytic with short t<sub>1/2</sub>\\ • Said to reduce blood loss by ~50%\\ • 1g tds - qid.   |
^Hormones  |• **progesterone only**\\ • although safer than combined pill, not usually recommended because of irregular and unpredictable blood loss\\ • May be appropriate if other options not available  |
^  |• **Norethisterone** = most common oral progesterone used.\\ • Said to reduce blood loss by ~80%.\\ • 5mg - tds  |
^  |• **combined pill** - oestrogen risk of VTE, CVS disease, stroke and breast CA  |

====Bleeding in early pregnancy====
  *<6/40, painless bleeding, consider expectant management
  *Advise pt to repeat urine pregnancy test in 7–10/7 and return if test +ve or symptoms continue or worsen
  *should be referred if +ve urine pregnancy test, or continuing or worsening symptoms to EPAU

Progesterone levels in pregnancy: [[https://www.ucsfhealth.org/medical-tests/serum-progesterone#:~:text=Pregnancy%201st%20trimester%3A%2011.2%20to,954%20or%20more%20nmol%2FL|Prog levels]]
  *Pregnancy 1st trimester: 11.2 to 90.0 ng/mL or **35.62 to 286.20 nmol/L**
  *Pregnancy 2nd trimester: 25.6 to 89.4 ng/mL or **81.41 to 284.29 nmol/L**
  *Pregnancy 3rd trimester: 48 to 150 to 300 or more ng/mL or **152.64 to 477 to 954 or more nmol/L**

==References include:==
https://www.nice.org.uk/guidance/ng88\\  
https://emedicine.medscape.com/article/255540-overview\\  
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728737/|Medical Mx heavy menstrual bleeding]]\\  
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142441/|Workup and Mx]]\\  
https://cks.nice.org.uk/miscarriage#!scenario\\