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Dysfunctional Uterine Bleeding in Emergency Medicine Treatment & Management

  • Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Nov 08, 2015
 

Approach Considerations

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.

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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.[3]

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.[12]

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.[11]

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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.[15]

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.[16]  Findings and recommendations included the following[16] :

  • 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.[17] Factors associated with a greater risk of treatment failure and subsequent procedures included tubal ligation, dysmenorrhea, and obesity.[17]

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Consultations

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.[18]  Note the following[18] :

  • 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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Contributor Information and Disclosures
Author

Amir Estephan, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn

Amir Estephan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Nedra R Dodds, MD, to the development and writing of this article.

References
  1. Frick KD, Clark MA, Steinwachs DM, et al. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Womens Health Issues. 2009 Jan-Feb. 19(1):70-8. [Medline].

  2. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Abnormal uterine bleeding. Williams Gynecology. New York: McGraw-Hill; 2008. 219-45.

  3. Tibbles CD. Selected gynecologic disorders. Marx JA, Hockberger RS, Walls RM, Adams JG. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Mosby (Elsevier); 2009. Vol 1: Chap 98.

  4. Pitkin J. Dysfunctional uterine bleeding. BMJ. 2007 May 26. 334(7603):1110-1. [Medline].

  5. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013 Sep-Oct. 20 (5):562-72. [Medline].

  6. van der Voet LF, Bij de Vaate AM, Veersema S, Brolmann HA, Huirne JA. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014 Jan. 121 (2):236-44. [Medline].

  7. Deligeoroglou E, Karountzos V, Creatsas G. Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. Gynecol Endocrinol. 2012 Sep 5. [Medline].

  8. Davidson BR, Dipiero CM, Govoni KD, Littleton SS, Neal JL. Abnormal uterine bleeding during the reproductive years. J Midwifery Womens Health. 2012 May-Jun. 57(3):248-54. [Medline].

  9. [Guideline] James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. 2009 Jul. 201(1):12.e1-8. [Medline].

  10. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul. 120 (1):197-206. [Medline].

  11. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008 Jun. 35(2):219-34, viii. [Medline].

  12. Hickey M, Higham J, Fraser IS. Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. 2007 Oct 17. CD001895. [Medline].

  13. [Guideline] American College of Obstetricians and Gynecologists. Management of abnormal uterine bleeding associated with ovulatory dysfunction. National Guideline Clearinghouse. Available at http://guideline.gov/content.aspx?id=47451. Accessed: Oct 31 2014.

  14. [Guideline] Roach L. Uterine Bleeding: ACOG Updates Guidelines. Medscape Medical News. June 21 2013. [Full Text].

  15. 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 Jun. 208(6):499.e1-5. [Medline].

  16. Laberge P, Leyland N, Murji A, et al, for the Society of Obstetricians and Gynaecologists of Canada. Endometrial ablation in the management of abnormal uterine bleeding. J Obstet Gynaecol Can. 2015 Apr. 37 (4):362-79. [Medline].

  17. Smithling KR, Savella G, Raker CA, Matteson KA. Preoperative uterine bleeding pattern and risk of endometrial ablation failure. Am J Obstet Gynecol. 2014 Nov. 211 (5):556.e1-6. [Medline].

  18. Dickersin K, Munro MG, Clark M, et al. Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2007 Dec. 110(6):1279-89. [Medline].

 
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