What are the medications and dosages for managing vaginal bleeding in the emergency department?

From the Guidelines

For hemodynamically stable patients with abnormal uterine bleeding, first-line treatment includes tranexamic acid 1000-1300 mg orally three times daily for up to 5 days, which reduces bleeding by inhibiting fibrinolysis, as recommended by the most recent guidelines 1.

Management of Vaginal Bleeding

In the emergency department, management of vaginal bleeding depends on the cause and severity. The following treatment options may be considered:

• Tranexamic acid 1000-1300 mg orally three times daily for up to 5 days, which reduces bleeding by inhibiting fibrinolysis 1
• Combined hormonal contraceptives, such as one pill containing ethinyl estradiol 35 mcg four times daily for 7 days, then tapered to three times daily for 7 days, then twice daily for 7 days, then once daily for 7 days 1
• IV conjugated estrogens 25 mg every 4-6 hours for 24 hours can rapidly control heavy bleeding
• For patients with retained products of conception, misoprostol 800 mcg vaginally or 600 mcg sublingually may be effective
• In cases of severe hemorrhage with hemodynamic instability, fluid resuscitation with isotonic crystalloids and blood products should be initiated while addressing the underlying cause

Considerations for Specific Patient Groups

• For patients with ectopic pregnancy, methotrexate 50 mg/m² IM as a single dose may be required if they meet specific criteria
• For postpartum hemorrhage, oxytocin 10-40 units IV infusion, methylergonovine 0.2 mg IM every 2-4 hours, or carboprost tromethamine 250 mcg IM every 15-90 minutes (maximum 8 doses) may be used
• For patients with pelvic ring disruption in hemorrhagic shock, early pelvic ring closure and stabilization should be performed

Key Principles

• Explore patient goals, including continued method use or method discontinuation 1
• Consider underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions
• Treatments should be tailored to the patient's preferences, treatment goals, and medical history 1

From the FDA Drug Label

In a single-center, randomized, double-blind clinical study that included premenopausal women with secondary amenorrhea for at least 90 days, administration of 10 days of Progesterone Capsules therapy resulted in 80 percent of women experiencing withdrawal bleeding within 7 days of the last dose of Progesterone Capsules, 300 mg per day (n=20), compared to 10 percent of women experiencing withdrawal bleeding in the placebo group (n=21). In a multicenter, parallel-group, open label, postmarketing dosing study that included premenopausal women with secondary amenorrhea for at least 90 days, administration of 10 days of Progesterone Capsules during two 28-day treatment cycles, 300 mg per day (n=107) or 400 mg per day (n=99), resulted in 73.8 percent and 76. 8 percent of women, respectively, experiencing withdrawal bleeding.

The medication Progesterone Capsules may be used to treat vaginal bleeding in the emergency department, specifically for women with secondary amenorrhea. The recommended dosage is 300-400 mg per day for 10 days. This treatment has been shown to induce withdrawal bleeding in a significant percentage of women, with rates ranging from 73.8% to 80%. However, it is essential to note that these studies were conducted in women with secondary amenorrhea, and the effectiveness of this treatment for vaginal bleeding in other contexts may vary. 2 2

From the Research

Medications for Vaginal Bleeding in the Emergency Department

• Methotrexate: used to treat ectopic pregnancy, with a single-dose or two-dose protocol 3, 4
• Tranexamic acid: used to manage heavy vaginal bleeding, including menstrual bleeding and postpartum hemorrhage 5, 6

Dosage and Administration

• Methotrexate: the dosage and administration protocol may vary depending on the patient's condition and the medical team's experience 3, 4
• Tranexamic acid: the dosage and administration protocol is not specified in the provided studies, but it is mentioned as a safe and effective treatment for heavy vaginal bleeding 6

Treatment Approaches

• Medical management: methotrexate and tranexamic acid can be used as a first-line treatment option for ectopic pregnancy and heavy vaginal bleeding, respectively 5, 6
• Surgical intervention: may be necessary in some cases, but medical management can help preserve the uterus and reduce the risk of complications 5, 7

Patient Evaluation and Referral

• The emergency physician should evaluate the patient's condition and provide initial therapy for vaginal bleeding, with referral to a gynecologist for further evaluation and treatment as needed 7