Dysfunctional Uterine Bleeding in Emergency Medicine Treatment & Management
- Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
Patients with severe, acute abnormal uterine bleeding and hemodynamic instability will require urgent gynecologic consultation and hospitalization.
Patients with bleeding heavy enough to decrease hematocrit may be given ferrous sulfate tablets (325 mg tid). Hormone regimens, including combination oral contraceptives and cyclic progestins, may be continued for several months under the supervision of the consulting gynecologist.
For long-term monitoring, most patients with abnormal uterine bleeding without hemodynamic compromise should be referred to a gynecologist for definitive management on an outpatient basis.
Emergency Department Care
Hemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock.
Evaluate ABCs and address the priorities.
Initiate 2 large-bore intravenous lines (IVs), oxygen, and cardiac monitor.
If bleeding is profuse and the patient is unresponsive to initial fluid management, consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stops.
In women with severe, persistent uterine bleeding, an immediate dilation and curettage (D&C) procedure may be necessary.
Combination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities. An oral contraceptive with 35 mcg of ethinyl estradiol can be taken twice a day until the bleeding stops for up to 7 days, at which time the dose is decreased to once a day until the pack is completed. They provide the additional benefits of reducing dysmenorrhea and providing contraception. Side effects include nausea and vomiting.
Progesterone alone can be used to stabilize an immature endometrium. It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation. Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days, followed by withdrawal bleeding 3-5 days after completion of the course. Currently, there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea. NSAIDs inhibit cyclooxygenase in the arachidonic acid cascade, thus inhibiting prostaglandin synthesis and increasing thromboxane A2 levels. This leads to vasoconstriction and increased platelet aggregation. These medications may reduce blood loss by 20-50%. NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its duration.
Danazol creates a hypoestrogenic and hyperandrogenic environment, which induces endometrial atrophy resulting in reduced menstrual loss. Side effects include musculoskeletal pain, breast atrophy, hirsutism, weight gain, oily skin, and acne. Because of the significant androgenic side effects, this drug is usually reserved as a second-line treatment for short-term use prior to surgery.
Gonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass. They produce a profound hypoestrogenic state similar to menopause. Side effects include menopausal symptoms and bone loss with long-term use.
Tranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen. It diminishes fibrinolytic activity within endometrial vessels to prevent bleeding. It has been shown effective in reducing bleeding in up to half of women with dysfunctional uterine bleeding. Tranexamic acid is not approved for the treatment of dysfunctional uterine bleeding in the United States.
Other Treatment Considerations
The American College of Obstetricians and Gynecologists offers guidelines regarding the treatment of abnormal uterine bleeding associated with ovulatory dysfunction; they include the following level B recommendations and conclusions (ie, those based on limited or inconsistent scientific evidence)[13, 14] :
The levonorgestrel intrauterine device (IUD) has been shown to be effective in treating abnormal uterine bleeding and should be considered for all age groups
Medical treatment options for abnormal uterine bleeding associated with ovulatory dysfunction include progestin therapy and combined hormonal contraception
Women who have completed childbearing, in whom medical therapy has failed, or who have contraindications to medical therapy are candidates for hysterectomy without cervical preservation
Because abnormal uterine bleeding associated with ovulatory dysfunction is an endocrinologic abnormality, the underlying disorder should be treated medically rather than surgically; surgical therapy is rarely indicated for the treatment of abnormal uterine bleeding associated with ovulatory dysfunction unless medical therapy fails, is contraindicated, or is not tolerated by the patient, or unless the patient has significant, concomitant intracavitary lesions
A study by Ammerman and Nelson indicated that outpatient treatment combining an injection of depo-medroxyprogesterone acetate with oral medroxyprogesterone can stop acute abnormal uterine bleeding. In the prospective, single-arm, pilot clinical trial, 48 nonpregnant, premenopausal women who were experiencing abnormal uterine bleeding were given an intramuscular injection of 150 mg of depo-medroxyprogesterone acetate and were prescribed 20 mg of medroxyprogesterone, which was to be taken orally every 8 hours for 3 days. Within 5 days, all 48 patients had stopped bleeding, with the mean time to bleeding cessation being 2.6 days.
The Society of Obstetricians and Gynaecologists of Canada has provided evidence-based guidelines on the techniques and technologies used in endometrial ablation for the management of abnormal uterine bleeding (AUB) of benign origin. Findings and recommendations included the following :
Endometrial ablation is a safe, effective, and minimally invasive alternative to medical treatment or hysterectomy to treat AUB in select women
For resectoscopic endometrial ablation, preoperative endometrial thinning results in higher short-term amenorrhea rates, decreased irrigant fluid absorption, and shorter operative time than no treatment.
Nonresectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter operative times, and allow the use of local rather than general anesthesia. However, both techniques have comparable patient satisfaction and reduction of heavy menstrual bleeding.
Low-risk patients with satisfactory pain tolerance are good candidates to undergo endometrial ablation in settings outside the operating room or in free-standing surgical centers.
Counsel patients about the need for permanent contraception following endometrial ablation.
Among women who had an endometrial ablation, Smithling et al found no differences in treatment failure or the need for subsequent procedures between women with regular and irregular bleeding. Factors associated with a greater risk of treatment failure and subsequent procedures included tubal ligation, dysmenorrhea, and obesity.
Seek an emergency gynecologic consultation for patients requiring hemodynamic stabilization. If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient, an emergency D&C may be warranted.
Consultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails. Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates. Note the following :
Endometrial ablation may be performed using laser, electrocautery, or rollerball. Amenorrhea is seen in approximately 35% of women treated, and decreased flow is seen in another 45%; although, treatment failures increase with time following the procedure due to endometrial regeneration. A substantial number of patients receiving endometrial ablation require reoperation (30% by 48 months).
Hysterectomy is the most effective treatment for bleeding. However, it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures. Operating time, hospitalization, recovery times, and costs are also greater. Hence, hysterectomy is reserved for selected patient populations.
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