Template:Non pregnant vaginal bleeding treatment: Difference between revisions
(→‎Moderate continued bleeding: Updated to reflect current recommendations from ACOG. These are also found in Tintinalli's and UpToDate.)
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===Moderate continued bleeding===
===Moderate continued bleeding===
Patients can benefit from initiation of birth control or for acute cessation consider medroxyprogesterone therapy in the ED
Patients may benefit from initiation of short or long-term birth control for acute cessation.
*'''Medroxyprogesterone'''
 
**Give only if endocervical curettage/endometrial biopsy does not need to be performed (young patient) or has already been performed, since the hormone may alter the results
'''Combined OCPs'''
**'''High Dose regimen:''' 150mg IM x 1 then 20mg PO Q8hrs x 3 days
*Any combined OCP that contains '''35 ug of ethinyl estradiol TID for 7 days'''. (e.g., Ortho-Novum 1/35®)<ref name="ACOG">Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 121:891–6. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women</ref>
**88% success, median time 3 days <ref>Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006 Oct;108(4):924-9. doi: 10.1097/01.AOG.0000238343.62063.22. PMID: 17012455.</ref>
*Contraindications
** Cigarette smoking if older than 34 years
** HTN
** Hx of VTE
** Cerebrovascular disease
** CAD or valvular disease
** Hx of breast cancer
** Diabetes with vascular involvement
** Surgery with immobilization
** Liver cirrhosis
** Other pro-coagulative coditions (e.g. Lupus, Factor V Leiden)
 
'''Medroxyprogesterone'''
*'''20 mg PO TID for 7 days'''<ref name="ACOG" />
**76% success, median time 3 days
*Alternative, not officially endorsed by ACOG: 150mg IM x 1 then 20 mg PO TID x 3 days
**In a trial of 48 patients all had cessation in 5 days.<ref name="highdose">Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013. 208(6):499.e1-e5.</ref>
**In a trial of 48 patients all had cessation in 5 days.<ref name="highdose">Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013. 208(6):499.e1-e5.</ref>
**'''Alternative regimen:''' 10mg PO q8 x 7 days then 10mg daily x 3 weeks<ref> Aksu F, Madazli R et al. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust N Z J Obstet Gynaecol. 1997;37(2):228–231.</ref>
*Contraindications
** Hx of VTE
** Hx of aterial thromboembolic events
** Hx of breast cancer
** Liver disease
<br>
 
If you are concerned for malignancy, hormonal therapy should be avoided until patient can be evaluated by OBGYN for possible biopsy, since these medications can interfere with those results.


===Life Threatening===
===Life Threatening===

Revision as of 04:34, 9 January 2024

Mild Bleeding

  • Iron supplementation
    • 324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
  • Ibuprofen
    • For cramps and can theoretically decreases intra-uterine bleeding
    • Reduces endometrial prostaglandin levels and promotes vasoconstriction in the uterus

Moderate continued bleeding

Patients may benefit from initiation of short or long-term birth control for acute cessation.

Combined OCPs

  • Any combined OCP that contains 35 ug of ethinyl estradiol TID for 7 days. (e.g., Ortho-Novum 1/35®)[1]
    • 88% success, median time 3 days [2]
  • Contraindications
    • Cigarette smoking if older than 34 years
    • HTN
    • Hx of VTE
    • Cerebrovascular disease
    • CAD or valvular disease
    • Hx of breast cancer
    • Diabetes with vascular involvement
    • Surgery with immobilization
    • Liver cirrhosis
    • Other pro-coagulative coditions (e.g. Lupus, Factor V Leiden)

Medroxyprogesterone

  • 20 mg PO TID for 7 days[1]
    • 76% success, median time 3 days
  • Alternative, not officially endorsed by ACOG: 150mg IM x 1 then 20 mg PO TID x 3 days
    • In a trial of 48 patients all had cessation in 5 days.[3]
  • Contraindications
    • Hx of VTE
    • Hx of aterial thromboembolic events
    • Hx of breast cancer
    • Liver disease


If you are concerned for malignancy, hormonal therapy should be avoided until patient can be evaluated by OBGYN for possible biopsy, since these medications can interfere with those results.

Life Threatening

  • Establish large bore IV access
  • Prepare for emergent blood transfusion uncrossmatched O-negative blood if typed blood is not available.
  • It is possible to temporize bleeding w/ intravaginal packing with kerlix soaked in with thrombin
  • If bleeding is due to a traumatic cause emergent surgical repair is necessary
  • Tranexamic acid [4]
    • Coordinate with OBGYN prior to administration due to the increased thrombotic risk
    • Acutely 1.0-1.3 grams IV
    • Then 1-1.3 g TID PO for 5 days

Pharmacologic Treatment Regimens For Acute Abnormal Uterine Bleeding[5][6]

Drug Suggested Dose Contraindications
Conjugated equine estrogen 25 mg IV every 4-6 h until bleeding stops, up to 24 h Active or past thromboembolic disease, breast cancer, or liver disease
Combination oral contraceptive pills 1 pill tid PO for 7 days or 1 pill bid PO for 5 days, then 1 pill qd until pack is finished > 35 y who smoke, hx of DVT or PE, breast cancer, liver disease, known thromboembolic disorders, pregnancy, ischemic heart disease, cerebrovascular disease, or uncontrolled hypertension
Progestin-only oral contraceptive pills (medroxyprogesterone acetate) 20 mg tid PO for 7 days or 10 mg qd PO for 10 days Active or past DVT or PE, liver disease, or breast cancer
NSAIDs: Ibuprofen 200-400 mg 3-4 times/day PO for 5 days Advanced renal disease
Antifibrinolytic agents (tranexamic acid) 1.3 g tid PO for up to 5 days Active intravascular clotting or subarachnoid hemorrhage
  1. ↑ 1.0 1.1 Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 121:891–6. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women
  2. ↑ Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006 Oct;108(4):924-9. doi: 10.1097/01.AOG.0000238343.62063.22. PMID: 17012455.
  3. ↑ Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013. 208(6):499.e1-e5.
  4. ↑ Leminen and Hurskainen. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health. 2012; 4: 413–421.
  5. ↑ American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 557: management of acute abnormal uterine bleeding in nonpregnant reproductiveaged women. Obstet Gynecol. 2013;121(4):891-896
  6. ↑ Tibbles CD. Selected gynecologic disorders: abnormal uterine bleeding in the nonpregnant patient. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby-Elsevier; 2010: 1325-1332.
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