Medication Options for Acute Vaginal Bleeding Episodes
Immediate Hormonal Management
For acute non-traumatic vaginal bleeding in a non-pregnant adult woman without contraindications to hormonal therapy, combined oral contraceptives (COCs) containing 30-35 μg ethinyl estradiol are the first-line treatment, administered in a multidose regimen to rapidly control bleeding. 1, 2
High-Dose Hormonal Regimens for Acute Bleeding
Multidose COC regimen: Administer monophasic COCs containing 30-35 μg ethinyl estradiol with a progestin (levonorgestrel or norgestimate) every 6-8 hours until bleeding stops, then taper to once daily 2, 3
High-dose estrogen therapy: Parenteral or oral estrogen can be used for acute bleeding episodes, particularly when bleeding results in hemodynamic instability 2, 3
Multidose progestin-only regimen: High-dose oral or injectable progestin-only medications may be considered short-term for hemodynamically unstable women with uncontrolled bleeding 1, 2
Adjunctive Non-Hormonal Options
Tranexamic acid: Can be administered for 5 days as an effective option for acute bleeding, particularly when hormonal therapy needs augmentation or when immediate pregnancy is desired 2, 4
NSAIDs: Should be used for 5-7 days in combination with hormonal methods to decrease menstrual bleeding 1, 5, 2
Transitioning to Maintenance Therapy
After acute bleeding is controlled with the multidose regimen, transition to standard dosing of COCs (one pill daily) for ongoing management 2, 3. The patient should continue taking hormonal pills for at least 21 consecutive days before any hormone-free interval to prevent recurrent bleeding. 6
Maintenance Regimen Options
Standard cyclic COCs: Monophasic pills with 30-35 μg ethinyl estradiol taken for 21-24 days followed by 4-7 hormone-free days 6, 1
Extended/continuous regimens: Active pills taken continuously for 3-4 months followed by a 4-7 day hormone-free interval, particularly useful for preventing recurrent heavy bleeding 1, 7
If breakthrough bleeding occurs during extended regimens, allow a 3-4 day hormone-free interval (but not during the first 21 days of use and not more than once per month) 1, 5
Important Clinical Considerations
Contraceptive Coverage
No backup contraception is needed if COCs are started within the first 5 days of menstrual bleeding 6
Backup contraception for 7 days is required if COCs are started more than 5 days after menstrual bleeding began 6
Common Pitfalls to Avoid
Do NOT use DMPA (Depo-Provera) as first-line treatment for acute vaginal bleeding, as it commonly causes menstrual irregularities initially and should be reserved as a second-line option after COCs have been tried 7
Before treating breakthrough bleeding, always rule out pregnancy, sexually transmitted infections, new pathologic uterine conditions (polyps or fibroids), and medication interactions 6, 1, 5
Counsel patients that unscheduled spotting or bleeding is common during the first 3-6 months of COC use but generally improves with persistent use 6, 1
Monitoring Requirements
Blood pressure should be monitored at follow-up visits for patients on COCs 1, 5
No routine follow-up visit is required, but patients should return if experiencing side effects or concerns 1, 5
Assess satisfaction with the method and any health status changes at follow-up visits 1, 5
Alternative Options When COCs Are Contraindicated
If hormonal contraceptives are contraindicated due to cardiovascular risk factors or history of venous thromboembolism, tranexamic acid for 5 days remains an effective non-hormonal option for managing acute bleeding episodes 2, 4