Template:Non pregnant vaginal bleeding treatment: Difference between revisions
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''If you are concerned for malignancy, hormonal therapy should be avoided unless discussed with OBGYN, as these medications may interfere with possible biopsy results.''
===Mild Bleeding===
===Mild Bleeding===
*[[Iron supplementation]]
*[[Iron supplementation]]
**324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
**324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
*[[Ibuprofen]]
*[[NSAIDs]]
**For cramps and can theoretically decreases intra-uterine bleeding
**e.g. [[ibuprofen]] 400 mg PO q6h, or [[naproxen]] 500 mg PO BID
**Reduces endometrial prostaglandin levels and promotes vasoconstriction in the uterus
**For cramping pain and can decreases intra-uterine bleeding. Reduces endometrial prostaglandin levels and promotes vasoconstriction in the uterus


===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
** [[Hypertension]]
** History of [[VTE]]
** Cerebrovascular disease
** CAD or valvular disease
** History of breast cancer
** [[Diabetes]] with vascular involvement
** Surgery with immobilization
** Liver [[cirrhosis]]
** Other pro-coagulative conditions (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
** History of [[VTE]]
** History of arterial thromboembolic events
** History of breast cancer
** Liver disease


===Life Threatening===
===Life Threatening===
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| 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  
| 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
| Combination oral contraceptive pills ||1 pill TID PO for 7 days or 1 pill bid PO for 5 days, then 1 pill daily until pack is finished|| > 35 y who smoke, history 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
| Progestin-only oral contraceptive pills ([[medroxyprogesterone]] acetate)||20 mg TID PO for 7 days or 10 mg daily 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
| [[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
| Antifibrinolytic agents ([[tranexamic acid]]) ||1.3 g TID PO for up to 5 days||Active intravascular clotting or subarachnoid hemorrhage
|}
|}

Latest revision as of 22:30, 26 February 2025

If you are concerned for malignancy, hormonal therapy should be avoided unless discussed with OBGYN, as these medications may interfere with possible biopsy results.

Mild Bleeding

  • Iron supplementation
    • 324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
  • NSAIDs
    • e.g. ibuprofen 400 mg PO q6h, or naproxen 500 mg PO BID
    • For cramping pain and can 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
    • Hypertension
    • History of VTE
    • Cerebrovascular disease
    • CAD or valvular disease
    • History of breast cancer
    • Diabetes with vascular involvement
    • Surgery with immobilization
    • Liver cirrhosis
    • Other pro-coagulative conditions (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
    • History of VTE
    • History of arterial thromboembolic events
    • History of breast cancer
    • Liver disease

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 daily until pack is finished > 35 y who smoke, history 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 daily 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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