Medication Summary
Pharmacotherapy is aimed at preventing medical complications of abnormal uterine bleeding (AUB) and includes the following:
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Hormone therapy (eg, estrogen, combination estrogen-progestin) [33]
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Antiprostaglandins
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Antifibrinolytics [34]
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Iron supplements
Therapies such as gonadotropin-releasing hormone (GnRH) agonists and selective estrogen receptor modulators (SERMs) have a limited place in the treatment of unresponsive bleeding; however, further medical investigation is warranted to support their routine use. [35]
Estrogens
Class Summary
Anovulatory bleeding occurs as the hyperproliferative endometrium, lacking a progesterone effect, outgrows its estrogen supply, leading to irregular sloughing. Rapid return of adequate estrogen levels is the quickest way to decrease bleeding. Estrogens alone are primarily used for acute dysfunctional uterine bleeding when rapid control of the bleeding is required.
Estrogen, conjugated (Premarin)
Administered PO, IM, or IV. Studies have demonstrated that similar blood levels are achieved at the same rate by any route. Parenteral therapy is reserved for patients who are unable to tolerate PO intake. Equivalent doses of other forms of estrogen (eg, estradiol, esterified estrogens, ethinyl estradiol, estropipate) are likely to be equally effective although clinical studies are lacking. Only the conjugated estrogens are approved by the FDA for this indication.
Progestins
Class Summary
Individually, progestins are used to stabilize an estrogen-primed endometrium and are administered in a cyclic fashion. Because the pathophysiology of dysfunctional uterine bleeding is based on a relative estrogen deficiency, progestins alone should not be the first-line treatment for acute bleeding. Progestins should be administered along with estrogens, and this combination is discussed under oral contraceptive pills.
Continuous use of high-dose progestins, orally or in a depo-form, can induce endometrial atrophy and amenorrhea. This approach is useful for preventing future blood loss while correcting a significant anemia or when combination contraceptive pills do not achieve adequate control of bleeding.
Medroxyprogesterone (Amen, Provera, Depo-Provera)
May be administered PO, in a cyclic or continuous fashion, or as a parenteral depot formulation. When managing acute and heavy uterine bleeding, should be administered concurrently with an estrogen preparation. Progestins alone do not address the underlying pathophysiology of a hyperproliferative endometrium that has outgrown its estrogen supply.
Norethindrone (Aygestin, Micronor)
Administered PO in a cyclic or continuous fashion. When managing acute and heavy uterine bleeding, should be administered concurrently with estrogen. Progestins alone do not address the underlying pathophysiology of a hyperproliferative endometrium that has outgrown its estrogen supply.
Oral contraceptive agents
Class Summary
Oral contraceptive agents or oral contraceptive pills (OCPs) provide a convenient method of rapidly delivering high-dose combinations of estrogen and progestin. The monophasic preparations offer the best opportunity for creating a stable endocrine environment. Most of the modern products contain 20, 30, or 35 mcg of ethinyl estradiol in combination with norethindrone or one of the second- or third-generation progestins. For all practical purposes, they are essentially equivalent.
Ethinyl estradiol and desogestrel (Desogen)
This is one example of an OCP preparation. When treating light-flow irregular bleeding, OCPs are administered in the usual contraceptive fashion (ie, 1 tab PO qd for 21 d of a typical 28-d cycle). Treatment of acute heavy uterine bleeding, multiple tab are administered PO each day and then tapered once the heavy flow has ceased. If significant anemia is present, the placebo phase (ie, days 22-28) may be omitted for several mo.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Class Summary
Studies have demonstrated a prostaglandin imbalance in women with menorrhagia and a reduction in menstrual flow with administration of NSAIDs. Several drugs in this category should have similar efficacy.
Ibuprofen (Motrin, Advil, Ibuprin)
A classic example of this category of medications. For best efficacy, start the NSAID prior to the onset of flow. Have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is nonselective inhibition of cyclooxygenases 1 and 2, resulting in reduced synthesis of prostaglandins and thromboxanes.
Antifibrinolytic agents
Class Summary
These agents inhibit fibrinolysis via inhibition of plasminogen activator substances, to a lesser degree, through antiplasmin activity.
Aminocaproic acid (Amicar)
Used for acute heavy uterine bleeding in patients with increased fibrinolytic activity. Discontinued once bleeding has stopped.
Iron salts
Class Summary
These are used to replenish iron stores lost during acute or chronic hemorrhage. The body stores iron in compounds called ferritin and hemosiderin for future use in the production of hemoglobin. Iron absorption is a variable of the existing body iron stores, the form and quantity in foods, and the combination of foods in the diet. The ferrous form of inorganic iron is more readily absorbed.
Ferrous sulfate (Feosol, Slow FE, Feostat)
This is the most common medication for iron therapy though several other formulations are available.
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Menstrual cycle.
