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ABNORMAL VAGINAL BLEEDING• BP < 90/60• Exclude pregnancy. If pregnant 93.• Following abortion or miscarriageManagement:• Give IV sodium chloride 0.9% and refer same day.Recognise the patient with vaginal bleeding needing urgent attention:Approach to the patient with abnormal vaginal bleeding not needing urgent attention• Refer within 2 weeks the patient with vaginal bleeding who is menopausal (no periods for at least one year).• In patient who is not menopausal determine the type of bleeding problem.Heavy regular bleeding with/without pain(bleeding > 7 days, passing clots)Any bleeding elsewhere (gums, easy bruising,rash)?Yes• Checkfull bloodcount.• Refer todoctorsameweek.No• If Hb < 11 give ferroussulphate compound BPC170mg 8 hourly after foodfor at least 3 months until Hb> 11.• During period, give ibuprofen400mg 8 hourly with food for2-3 days to decrease pain andblood loss.• If newly started oninjectable contraceptive,give levonorgestrel/ethinyloestradiol 0.15/0.03mg for3 cycles.• Refer the patient if:--Same week if abdominalmass--No better after 3 months--Following IUCD insertionPeriods have irregular pattern(< 24 days or > 35 days between periods)Does patient have hot flushes, moodswings and/or difficulty sleeping?Yes Patient isperimenopausal.98No• If there is weightgain, tiredness,feeling cold allthe time, checkTSH. Referto doctor ifabnormal.• Givelevonorgestrel/ethinyl oestradiol0.15mg/0.03mgfor 6 months91.• Refer togynaecologist ifpatient wantingto be pregnant.Spotting between periods• If STI symptoms: 23.• Do pap smear 27.If on hormonal contraception: manage according to methodOral contraceptive• Ensure correct use.• If diarrhoea and vomiting, advisecondom use until diarrhoea,vomiting and spotting resolve.• If on phenytoin, carbamazepine,rifampicin or lopinavir/ritonavir,change to IUCD or injectable.Bleeding after sex• If STI symptoms: 23.• If assault or abuse 53.Injectable contraceptive• Common in first 3–6months.• Give levonorgestrel/ethinyl oestradiol0.15/0.03mg for 7 days.Give ibuprofen 400mg8 hourly for 3 daysinstead if breast feeding,smoker > 35 years, BP≥140/90, migraine withfocal symptoms, DVT orpulmonary embolus.Refer the patient within 2 weeks if:• Unsure of diagnosis• Menopausal (no periods for at least 1 year)• Bleeding persists: > 1 week after STI treatment, after diarrhoea and vomiting stopor for > 3 months• Abnormal cervix on speculum examination (suspicious of cancer)29