What is the initial treatment for acute abnormal uterine bleeding?

Initial Treatment for Acute Abnormal Uterine Bleeding

For acute abnormal uterine bleeding, intravenous conjugated estrogen (25 mg) is the most effective initial treatment, administered slowly to avoid flushing and repeated in 6-12 hours if necessary. 1

Treatment Algorithm for Acute Abnormal Uterine Bleeding

First-Line Treatment

1. Intravenous Conjugated Estrogen

   • Dosage: 25 mg IV administered slowly
   • Timing: May repeat in 6-12 hours if necessary
   • Administration note: Give SLOWLY to prevent flushing
   • Compatibility: Compatible with normal saline, dextrose, and invert sugar solutions; not compatible with protein hydrolysate, ascorbic acid, or acidic solutions 1

2. Alternative First-Line Option: High-Dose Oral NSAIDs

   • Ibuprofen 400-800 mg three times daily for 5-7 days during bleeding episodes
   • Reduces menstrual blood loss by 25-39% compared to placebo 2
   • Generally well-tolerated for short-term use

Second-Line Options

1. Tranexamic Acid

   • Reduces menstrual blood loss by approximately 50%
   • Used for 4-5 days starting from the first day of menstrual cycle
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2

2. Progestin Therapy

   • Medroxyprogesterone acetate 20 mg orally every 8 hours for 3 days
   • Can be combined with depo-medroxyprogesterone acetate 150 mg intramuscular injection for enhanced effect 3

3. Dilation and Curettage (D&C)

   • Indicated for patients with acute bleeding resulting in hypovolemia
   • Also indicated for women with risk factors for endometrial cancer who have persistent bleeding 4

Important Clinical Considerations

Evaluation Before Treatment

• Rule out pregnancy as a cause of abnormal bleeding
• Assess for organic pathology (fibroids, polyps, malignancy)
• Evaluate hemodynamic stability - IV estrogen is particularly important for hemodynamically unstable patients

Contraindications and Cautions

• IV conjugated estrogen is indicated for short-term use only 1
• NSAIDs are not recommended for women with active thromboembolic disease 2
• Tranexamic acid is contraindicated in women with history or risk of thrombosis 2

Follow-up

• Follow up in 4-6 weeks if bleeding persists despite treatment
• Monitor hemoglobin/hematocrit if heavy bleeding continues 2
• Consider imaging studies if bleeding persists:
  • Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study
  • MRI of the pelvis without and with contrast if the uterus is incompletely visualized on ultrasound 5

Long-Term Management After Acute Episode

After controlling the acute bleeding episode, consider these options for long-term management:

1. Hormonal Contraceptives

   • Low-dose combined oral contraceptives (≤35 μg ethinyl estradiol)
   • Levonorgestrel-releasing intrauterine device (LNG-IUD) - highly effective with failure rate of 0.1-0.2% 2
   • Depot medroxyprogesterone acetate (DMPA) - may lead to amenorrhea, failure rate 0.3-6% 2

2. Cyclic Progestin Therapy

   • Medroxyprogesterone acetate for 10 days each month for 3-6 months 4

3. For Ovulatory Dysfunctional Uterine Bleeding

   • NSAIDs, antifibrinolytic agents, or combination therapy may be required 4

Common Pitfalls to Avoid

• Failing to rule out pregnancy before initiating hormonal treatment
• Not considering von Willebrand's disease, which is present in approximately 1% of the population and can be misdiagnosed as dysfunctional uterine bleeding 4
• Using estrogen therapy in patients with chronic anovulation without appropriate progestin, which increases risk of endometrial hyperplasia and cancer 6
• Delaying treatment in hemodynamically unstable patients - these patients require immediate intervention with IV estrogen and possibly D&C 4