What is the emergency department treatment for abnormal uterine bleeding (AUB)?

From the Guidelines

Emergency department treatment of abnormal uterine bleeding should focus on stabilizing the patient, controlling active bleeding, and determining the underlying cause, with high-dose estrogen therapy or tranexamic acid being potential first-line treatments for hemodynamically stable patients. For hemodynamically stable patients with heavy bleeding, high-dose estrogen therapy, such as IV conjugated estrogens (Premarin) 25mg every 4-6 hours until bleeding subsides, or oral combined hormonal contraceptives, can be effective in controlling bleeding 1. Alternatively, tranexamic acid 1000-1300mg orally three times daily for 5 days can effectively reduce bleeding by inhibiting fibrinolysis, as seen in studies on uterine leiomyomas 1.

Key Considerations

• Hemodynamically unstable patients with severe bleeding require fluid resuscitation, blood transfusion if hemoglobin is below 7g/dL, and urgent gynecological consultation.
• Patients should undergo pregnancy testing and assessment for coagulopathies to determine the underlying cause of bleeding.
• The treatment approach varies based on the cause of bleeding, with hormonal therapy being most effective for anovulatory bleeding, while structural causes may require surgical intervention, as outlined in the PALM-COEIN classification system 1.
• Medical treatments, such as progestin-only contraception and combined hormonal contraception, can be effective for abnormal uterine bleeding associated with ovulatory dysfunction, but may not be suitable for all patients, particularly those with concomitant significant intracavitary lesions 1.

Treatment Options

• High-dose estrogen therapy: IV conjugated estrogens (Premarin) 25mg every 4-6 hours until bleeding subsides.
• Tranexamic acid: 1000-1300mg orally three times daily for 5 days.
• Oral combined hormonal contraceptives: monophasic pills containing ethinyl estradiol 35mcg, one pill every 6 hours until bleeding slows, then one pill three times daily for 7 days, followed by one daily for 3 weeks.
• NSAIDs: ibuprofen 600mg every 6 hours to reduce blood loss.

Follow-up

Patients should be discharged with appropriate follow-up with a gynecologist within 1-2 weeks to address the underlying cause and prevent recurrence, as the treatment approach may vary based on the cause of bleeding 1.

From the FDA Drug Label

For treatment of abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology: One 25 mg injection, intravenously or intramuscularly. Intravenous use is preferred since more rapid response can be expected from this mode of administration. Repeat in 6 to 12 hours if necessary

The emergency department treatment for abnormal uterine bleeding (AUB) due to hormonal imbalance is 25 mg of conjugated estrogens administered intravenously or intramuscularly, with the option to repeat in 6 to 12 hours if necessary 2.

• Key points:
  • Dose: 25 mg
  • Route: Intravenous or intramuscular
  • Repeat: 6 to 12 hours if necessary
• Important consideration: The use of conjugated estrogens for injection does not preclude the advisability of other appropriate measures 2.

From the Research

Emergency Department Treatment for Abnormal Uterine Bleeding (AUB)

• The treatment for AUB in the emergency department involves a detailed history, pelvic examination, and laboratory testing, including a pregnancy test and complete blood count 3.
• For patients with severe bleeding that causes hemodynamic instability, emergency interventions include:
  • Uterine tamponade
  • Intravenous estrogen
  • Dilation and curettage
  • Uterine artery embolization 3
• Medical management is the preferred initial approach for hemodynamically stable patients, with options including:
  • Oral estrogen
  • High-dose estrogen-progestin oral contraceptives
  • Oral progestins
  • Intravenous tranexamic acid 3, 4
• The most effective long-term medical treatment for heavy menstrual bleeding is the levonorgestrel-releasing intrauterine system, with other options including estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, nonsteroidal anti-inflammatory drugs, and depot medroxyprogesterone 3, 4, 5

Considerations for Treatment

• The choice of treatment depends on the etiology and amount of bleeding, need for contraception or preservation of fertility, perimenopause status, and medication efficacy and adverse effects 5
• Patients with structural lesions may require surgical procedures, while those with non-structural etiologies may be managed with medical therapy 3, 6
• The patient's desire for current or future fertility should be considered when determining the management plan 6