Managing acute heavy menstrual bleeding
Recommendations for hormonal regimens to halt blood loss in the outpatient
A 32-year-old G4P2022 with a body mass index (BMI) of 32 kg/m2 presents with a history of heavy and prolonged bleeding for 10 days. She is slightly fatigued but denies any dizziness or shortness of breath. She reports that she has soaked 12 thick sanitary napkins in the last 24 hours. Normally her menses occur every 28 to 32 days and last for 4 days with moderate flow (3–4 pads per day). She relies on her husband’s vasectomy for birth control. She is slightly tachycardic, but has no orthostatic changes in her vital signs. Her hemoglobin is 9.1. Pelvic exam reveals moderate blood flow from her cervical os. She has a slightly enlarged uterus with no signs of infection. Her urine pregnancy test is negative.
Acute abnormal uterine bleeding is not an uncommon challenge facing practitioners who care for women. The new International Federation of Gynecology and Obstetrics (FIGO) classification system defines it as an episode of heavy bleeding that, in the opinion of the clinician, is of sufficient quantity to require immediate intervention to prevent future blood loss.1 The evaluation that a woman with acute abnormal uterine bleeding needs has been outlined in 2 recent American College of Obstetricians and Gynecologists (ACOG) bulletins and one ACOG Committee Opinion.2-4 Those guidelines emphasize that the workup for acute excessive uterine bleeding depends upon a woman’s age, her medical and menstrual history, her risk factors for endometrial pathology, and her prior laboratory results.
This patient is hemodynamically stable and does not need transfusion or hospitalization. It will not be possible to determine her formal diagnosis until the results of her tests are available.1-4 However, the challenge facing the clinician is that the patient needs treatment now to stop her excessive bleeding.
Hormonal management is first-line medical therapy for patients with acute abnormal uterine bleeding.4,5 However, there is no consistency among the hormonal regimens recommended and very little or no scientific evidence of efficacy for any of them. For example, medroxyprogesterone acetate (MPA) 10 mg a day for 10 days is often prescribed in emergency departments. Obstetrician-gynecologists themselves have developed different so-called oral contraceptive (OC) tapers with 4-3-2-1 OC tablets prescribed for consecutive days or 3-3-2-2-1 birth control pills to be taken on specified days.
A recent European Consensus group offered 4 oral options for hormonal treatment of acute bleeding in women without underlying bleeding disorders: birth control pills with either 30 mcg or 50 mcg of ethinyl estradiol (EE) in combination with any progestin to be taken every 6 hours until bleeding stops (with a re-evaluation at 48 hours); norethindrone acetate 5 mg–10 mg every 4 hours; or MPA 10 mg every 4 hours (up to 80 mg per day). Each regimen had an accompanying taper protocol.5 Interestingly, the source for these options was an adolescent health protocol; no clinical studies were cited.