Managing an episode of severe or prolonged uterine bleeding
- Howard A Zacur, MD, PhD
Howard A Zacur, MD, PhD
- Professor of Gynecology and Obstetrics
- Johns Hopkins University School of Medicine
An episode of heavy or prolonged uterine bleeding may occur either in women with normal menses or those with chronic abnormal uterine bleeding. These women present to a clinician's office or emergency room complaining of vaginal bleeding that is severe or has lasted for many days or weeks. Consequences of such episodes depend upon the volume of bleeding, and range from patient anxiety and interference with daily activities to severe anemia and hypovolemia. Evaluation and management of women experiencing such episodes must be expedited to establish the source of bleeding and prevent or treat excessive blood loss .
Evaluation and management of an episode of heavy or prolonged uterine bleeding will be reviewed here. The general evaluation and treatment of abnormal uterine bleeding, uterine bleeding in pregnancy, and approach to a woman with vaginal bleeding in the emergency department are discussed separately. (See "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women" and "Management of abnormal uterine bleeding" and "Overview of the etiology and evaluation of vaginal bleeding in pregnant women" and "Approach to vaginal bleeding in the emergency department".)
There is no standard definition of acute uterine bleeding. Acute uterine bleeding has been described as excessively heavy or prolonged bleeding of uterine origin sufficient in volume as to require urgent or emergent intervention . This may occur with ovulatory or anovulatory bleeding. In this review, we will use the term acute to refer to bleeding that is profuse, and not only of sudden onset.
Prolonged menses are defined as longer than seven days; in this review, we will apply this definition to either ovulatory or anovulatory bleeding and address women with an isolated episode of prolonged bleeding. Management of chronic prolonged uterine bleeding is discussed separately. (See "Management of abnormal uterine bleeding".)
Women with heavy or prolonged uterine bleeding generally complain of heavy vaginal bleeding that may soak through clothing or onto bedding. Women with this symptom also often report passing blood clots. The current episode may represent either a new onset of bleeding or an exacerbation of existing bleeding; it may be continuous or intermittent.
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- CLINICAL PRESENTATION
- Assess hemodynamic stability
- Evaluate for anemia and coagulopathy
- Confirm uterine source and assess volume of bleeding
- - History
- - Physical examination
- Identify structural abnormalities
- Sample the endometrium
- APPROACH TO MANAGEMENT
- HEMODYNAMICALLY UNSTABLE WOMEN
- Stabilizing the patient
- - Fluid resuscitation and blood product replacement
- - Intrauterine tamponade
- Therapeutic measures
- - Uterine curettage
- - High dose intravenous estrogen
- - Uterine artery embolization
- - Hysterectomy
- HEMODYNAMICALLY STABLE WOMEN
- High dose oral estrogen
- High dose oral contraceptives
- High dose progestins
- Gonadotropin-releasing hormone agonists
- Tranexamic acid
- Endometrial ablation
- WOMEN AT RISK OF THROMBOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS