Uterine Bleeding, Acute Abnormal — Hormone Treatment Table — Clinical Pathway: Emergency

Uterine Bleeding, Acute Abnormal Clinical Pathway — Emergency Department

Treatment of AUB

Goals of Treatment

  • Control current bleeding episode
  • Reduce blood loss in subsequent cycles and return to normal cycles
  • Prevent long-term consequences of anovulation

General Guidance

  • Hormones are 1st line treatment
  • Stabilizes endometrium, promotes normal cyclic shedding
  • Monophasic combined oral contraceptive (COC) or progesterone-only treatment
  • Review Contraindications of Estrogen Therapy
  • No consensus for dosing, titrate dose as needed for response
  • 90% have median time to cessation of bleeding is 72 hrs
  • Most benefit from at least 3 mos of hormonal treatment if poor response
  • Reassess for alternative diagnosis in those who do not respond
  • Tranexamic is an option if contraindications to hormone
Severe AUB: Hgb < 8 mg/dL with or without Hemodynamic Instability
Consider Admission
Consider blood transfusion for hemodynamic instability, no Hgb parameter
Monophasic Estrogen-Progesterone COC Progesterone only Other Treatment Follow-Up
  • Ethinyl estradiol/norgestrel
    0.03 mg/0.3 mg (Low-Ogestrel)
    • 1 tablet q4hr until bleeding stops
    • Increase to 2 tablets as needed
    • Once bleeding has stopped
    • Taper
      • 1-2 tablet q8hr for 3 days
      • 1-2 tablet q12hr for 2 wks
      • 1-2 tablet daily, no placebo until follow-up
  • Medroxyprogesterone (Provera)
    • 10 mg q6hr until bleeding stops
    • Increase dose to 20 mg as needed
    • Once bleeding has stopped
    • Taper
      • 10-20 mg q8hr for 3 days
      • 10-20 mg q12hr for up to 1 wk
      • 10-20 mg daily until follow-up
  • or
  • Norethindrone
    • 5 mg q6hr until bleeding stops
    • Increase to 10 mg q6hr as needed
    • Taper
      • 5-10 mg q8hr for 3 days
      • 5-10 mg q12hr for 1 wk
      • 5-10 mg daily until follow-up
  • Consider antifibrinolytics
    • Estrogen contraindications
    • Bleeding disorder
  • Consult Hematology
    • Tranexamic acid
    • Aminocaproic acid
    • Desmopressin
  • Consider IV Iron
  • Symptom treatment
    • Ondansetron
    • Stool softener
  • Adolescent subspecialty or Gynecology: 2 wks
  • Hematology as needed
  • Treatment
    • Daily hormone, no placebo
    • Ondansetron as needed
    • Fe Therapy
    • Stool softener
Moderate AUB: Hgb 8-12 mg/dL with Active Bleeding
Monophasic Estrogen-Progesterone COC Progesterone Only Follow-Up
  • Ethinyl estradiol/norgestrel
    0.03 mg/0.3 mg, (Low-Ogestrel)
    • 1 tablet q8hr for 3 days
  • Taper
    • 1 tablet q12hr for 2 days
    • 1 tablet daily, no placebo, until follow-up
  • Medroxyprogesterone (Provera)
    • 10 mg q8hr for 3 days
  • Taper
    • 10 mg q12hr for 2 days
    • 10 mg daily until follow-up
  • or
  • Norethindrone
    • 5 mg q8hr for 3 days
  • Taper
    • 5 mg q12hr for 2 days
    • 5 mg daily until follow-up
  • Adolescent subspecialty or Gynecology: 1 mo
  • Treatment
    • Daily hormone, no placebo
    • Ondansetron as needed
    • Fe Therapy
    • Stool softener
Moderate AUB: Hgb 8-12 mg/dL without Active Bleeding
Monophasic Estrogen-Progesterone COC Progesterone Only Follow-Up
  • Ethinyl estradiol/norgestrel
    0.03 mg/0.3 mg (Low-Ogestrel)
    • 1 tablet daily with placebo, until follow-up
  • Medroxyprogesterone (Provera)
    • 5 mg daily for 10 days beginning on the 1st day of the calendar month
  • or
  • Norethindrone
    • 5 mg daily for 10 days beginning on the 1st day of the calendar month
  • Adolescent subspecialty or Gynecology: 1-2 mos
  • Treatment
    • Daily hormone with placebo
    • Fe Therapy
    • Stool softener
    • Ondansetron as needed
Mild AUB: Hgb > 12 mg/dL
Monophasic Estrogen-Progesterone COC Progesterone Only Follow-Up
No hormonal therapy indicated, reassurance
  • PCP 2-3 mos
  • Treatment
    • Multivitamin with iron

Reference

Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding