Semin Reprod Med 2011; 29(5): 446-458
DOI: 10.1055/s-0031-1287668
© Thieme Medical Publishers

Management of Abnormal Uterine Bleeding in Low- and High-Resource Settings: Consideration of Cultural Issues

Rohana Haththotuwa1 , Malik Goonewardene2 , Shyam Desai3 , Lakshman Senanayake4 , Jaydeep Tank5 , Ian S. Fraser6
  • 1Ninewells CARE Mother and Baby Hospital, Colombo, Sri Lanka
  • 2Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
  • 3Department of Obstetrics and Gynaecology, Mothercare Nursing Home, Mumbai University
  • 4UNFPA Sri Lanka, Colombo, Sri Lanka
  • 5Assisted Reproduction and In Vitro Fertilization (IVF), Center for Advanced Endoscopy, Ashwini Maternity and Surgical Hospital, Mumbai, India
  • 6Department of Obstetrics and Gynaecology, University of Sydney, Camperdown, Australia
Further Information

Publication History

Publication Date:
07 November 2011 (online)


In non industrialized countries the incidence of heavy menstrual bleeding (HMB) appears to be similar to that of industrialized countries, although data is scanty. In low-resource settings, women with abnormal uterine bleeding (AUB) often delay seeking medical care because of cultural beliefs that a heavy red menstrual bleed is healthy. Efforts to modify cultural issues are being considered. A detailed history and a meticulous examination are the important foundations of a definitive diagnosis and management in low-resource settings but are subject to time constraints and skill levels of the small numbers of health professionals. Women's subjective assessment of blood loss should be combined, if possible, with a colorimetric hemoglobin assessment, if full blood count is not possible. Outpatient endometrial sampling, transvaginal sonography, and hysteroscopy are available in some non industrialized countries but not in the lowest resource settings. After exclusion of serious underlying pathology, hematinics should be commenced and antifibrinolytic or nonsteroidal anti-inflammatory drugs considered during menses to control the bleeding. Intrauterine or oral progestogens or the combined oral contraceptive are often the most cost-effective long-term medical treatments. When medical treatment is inappropriate or has failed, the surgical options available most often are myomectomy or hysterectomy. Hysteroscopic endometrial resection or newer endometrial ablation procedures are available in some centers. If hysterectomy is indicated the vaginal route is the most appropriate in most low-resource settings. In low-resource settings, lack of resources of all types can lead to empirical treatments or reliance on the unproven therapies of traditional healers. The shortage of human resources is often compounded by a limited availability of operative time. Governments and specialist medical organizations have rarely included attention to AUB and HMB in their health programs. Local guidelines and attention to training of doctors, midwives, and traditional health workers are critical for prevention and improvement in management of HMB and its consequences for iron deficiency anemia and postpartum hemorrhage, the major killer of young women in developing countries.


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Rohana HaththotuwaM.B.B.S. (SL) 

Ninewells CARE Mother & Baby Hospital

55/1, Kirimandala Mawatha, Colombo 5, Sri Lanka