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.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol 2013; 121:891. Reaffirmed 2017.
- Munro MG, Mainor N, Basu R, et al. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol 2006; 108:924.
- Mansfield PK, Voda A, Allison G. Validating a pencil-and-paper measure of perimenopausal menstrual blood loss. Womens Health Issues 2004; 14:242.
- Medical devices; labeling for menstrual tampon for the "ultra" absorbency. Food and Drug Administration, HHS. Final rule. Fed Regist 2000; 65:62282.
- Rhoades, R, Bell, D. Medical Physiology: Principles for clinical medicine, Lippincott Williams & Wilkins, Philadelphia 2009.
- Grimes DA. Estimating vaginal blood loss. J Reprod Med 1979; 22:190.
- Cole SK, Billewicz WZ, Thomson AM. Sources of variation in menstrual blood loss. J Obstet Gynaecol Br Commonw 1971; 78:933.
- Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.
- Fraser IS, McCarron G, Markham R, Resta T. Blood and total fluid content of menstrual discharge. Obstet Gynecol 1985; 65:194.
- Levin RJ, Wagner G. Absorption of menstrual discharge by tampons inserted during menstruation: quantitative assessment of blood and total fluid content. Br J Obstet Gynaecol 1986; 93:765.
- Fraser IS, Critchley HO, Munro MG, et al. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril 2007; 87:466.
- March CM. Bleeding problems and treatment. Clin Obstet Gynecol 1998; 41:928.
- Haynes PJ, Hodgson H, Anderson AB, Turnbull AC. Measurement of menstrual blood loss in patients complaining of menorrhagia. Br J Obstet Gynaecol 1977; 84:763.
- DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding--a double-blind randomized control study. Obstet Gynecol 1982; 59:285.
- Speroff, L, Fritz, M. Postmenopausal hormone therapy. In: Clinical Gynecologic Endocrinology and Infertility, 7th ed, Speroff, L, Fritz, M, Lippincott Williams & Wilkins, Baltimore, Maryland 2005.
- Zreik TG, Odunsi K, Cass I, et al. A case of fatal pulmonary thromboembolism associated with the use of intravenous estrogen therapy. Fertil Steril 1999; 71:373.
- Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North Am 2000; 27:219.
- Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA 1993; 269:1823.
- Aksu F, Madazli R, Budak E, et al. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust N Z J Obstet Gynaecol 1997; 37:228.
- Chuong CJ, Brenner PF. Management of abnormal uterine bleeding. Am J Obstet Gynecol 1996; 175:787.
- Preston JT, Cameron IT, Adams EJ, Smith SK. Comparative study of tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. Br J Obstet Gynaecol 1995; 102:401.
- http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm190551.htm (Accessed February 1, 2010).
- Sundström A, Seaman H, Kieler H, Alfredsson L. The risk of venous thromboembolism associated with the use of tranexamic acid and other drugs used to treat menorrhagia: a case-control study using the General Practice Research Database. BJOG 2009; 116:91.
- Taparia M, Cordingley FT, Leahy MF. Pulmonary embolism associated with tranexamic acid in severe acquired haemophilia. Eur J Haematol 2002; 68:307.
- Winkler UH. The effect of tranexamic acid on the quality of life of women with heavy menstrual bleeding. Eur J Obstet Gynecol Reprod Biol 2001; 99:238.
- Wellington K, Wagstaff AJ. Tranexamic acid: a review of its use in the management of menorrhagia. Drugs 2003; 63:1417.
- Berntorp E, Follrud C, Lethagen S. No increased risk of venous thrombosis in women taking tranexamic acid. Thromb Haemost 2001; 86:714.
- Iacobellis G, Iacobellis G. Combined treatment with tranexamic acid and oral contraceptive pill causes coronary ulcerated plaque and acute myocardial infarction. Cardiovasc Drugs Ther 2004; 18:239.
- Fraser IS, Porte RJ, Kouides PA, Lukes AS. A benefit-risk review of systemic haemostatic agents: part 2: in excessive or heavy menstrual bleeding. Drug Saf 2008; 31:275.
- Franchini M, Cianferoni L. Emergency endometrial resection in women with acute, severe uterine bleeding. J Am Assoc Gynecol Laparosc 2000; 7:347.
- Milad MP, Valle RF. Emergency endometrial ablation for life-threatening uterine bleeding as a result of a coagulopathy. J Am Assoc Gynecol Laparosc 1998; 5:301.
- Nichols CM, Gill EJ. Thermal balloon endometrial ablation for management of acute uterine hemorrhage. Obstet Gynecol 2002; 100:1092.
- Osuga Y, Okagaki R, Ozaki S, et al. Successful emergency endometrial ablation for intractable uterine bleeding in a postmenopausal woman complicated with liver cirrhosis and morbid obesity. Surg Endosc 2001; 15:898.
- Richards SR. Endometrial ablation for life-threatening abnormal uterine bleeding. A report of two cases. J Reprod Med 1994; 39:741.
- Chu MC, Zhang X, Gentzschein E, et al. Formation of ethinyl estradiol in women during treatment with norethindrone acetate. J Clin Endocrinol Metab 2007; 92:2205.
- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS