**9. Severe vaginal bleeding**

Severe vaginal bleeding may or may not be related to menstruation. Common causes are dysfunctional uterine bleeding (DUB), uterine fibroids, adenomyosis and genital tract malignancy.

Normal menstrual cycles range from 21-35 days, with the estimated blood loss less than 80 ml, with flow not more than 7 days. Most women who complain of heavy periods have normal loss. Extremely heavy menstrual loss is uncommon and other causes such as a miscarriage or a genital tract malignancy like carcinoma of the cervix or endometrial carcinoma should be ruled out. If the patient is symptomatic after a heavy menstrual loss, like having dizziness or fainting spells, appears pale or has tachycardia, she should be admitted to hospital for treatment.

Patients with massive vaginal bleeding require resuscitation which includes securing of intravenous access with a wide bore cannula, obtaining blood samples for a complete blood count and infusing of crystalloids. Possible causes of the vaginal bleeding should be ruled out. There is the need to correct anaemia with haematinics and even blood transfusion.

Control of bleeding may be achieved by use of haemostatic drugs like tranexamic acid (an antifibrinolytic agent) and ethamsylate, or by hormonals like medroxyprogesterone, prior to definitive treatment of the cause. Mirena, a levonorgestrel-impregnated intrauterine system, and endometrial ablation techniques like the NovaSure system may also be employed [42] for control of bleeding.

The definitive treatment is dependent on the cause and emergency dilatation and curettage (D&C), myomectomy, and even a hysterectomy (Fig. 4) are possibilities. For those emanating from gynaecological cancers referral to oncology units with expertise in their management is required.

**Figure 4.** Hysterectomy specimen of a 50-year old woman who had total abdominal hysterectomy and bilateral salpin‐ go-oophorectomy for uterine fibroids associated with menorrhagia.
