Template:Non pregnant vaginal bleeding treatment

If you are concerned for malignancy, hormonal therapy should be avoided until patient can be evaluated by OBGYN for possible biopsy, since these medications may interfere with those 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®)
  • 88% success, median time 3 days
• 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
  • 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.
• 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
  • 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

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