Version May 2024
| Choice of therapy | Drug | Dose and duration (oral) | Comments |
| Preferred for most patients: High-dose combined oral contraceptives* | Combined estrogen-progestin oral contraceptives containing 35 mcg ethinyl estradiol; combinations with 30 or 50 mcg of ethinyl estradiol have also been used. Use monophasic combinations only. | Multiple regimens have been described; tapering regimen examples for tablets containing 30, 35, or 50 mcg of ethinyl estradiol include:
| Option for patients without contraindications to estrogen therapy. Bleeding typically subsides within 48 hours. To improve tolerability, an antiemetic may be prescribed. Omit inactive (placebo) tablets. After acute bleeding resolves, begin maintenance treatment (eg, monthly or extended cycle COC regimen). |
| Alternative for patients who may benefit from a quicker onset of action: High-dose oral estrogen | Conjugated equine estrogen | 2.5 mg orally every 6 hours. When bleeding subsides or is minimal, the dose may be decreased to 2.5 mg orally twice daily. | Option for patients without contraindications to estrogen therapy. Bleeding typically subsides within 10 hours of first dose. Treatment is typically continued for not more than 21 to 25 days. After discontinuation, a progestin is then prescribed to induce a withdrawal bleed (eg, medroxyprogesterone acetate 10 mg once daily for 10 days). |
| Alternative for patients in whom the suspected etiology of acute bleeding is from anovulation: Oral progestins | Medroxyprogesterone acetate, or | 10 to 20 mg 3 times daily for 5 to 10 days. | Patients with anemia may benefit from longer durations (eg, a 1- to 2-month treatment period in conjunction with iron allows an increase in hemoglobin/hematocrit); however, long-term tolerability is limited by adverse effects (eg, acne, mood changes, weight gain, headache, lipid abnormalities). After resolution of acute bleeding, transition to maintenance dosing or another progestin (eg, levonorgestrel IUD). Refer to related UpToDate content. |
| Megestrol acetate, or | 20 to 60 mg 2 times daily for 5 to 10 days.Δ | ||
| Norethindrone | 5 mg 1 to 4 times daily for 5 to 10 days. | ||
| Treatments less commonly used | Tranexamic acid, or | 1.3 g 3 times daily.◊ | Subsequent-line therapy for patients not at high risk of thrombosis. Typically acts within 2 to 3 hours of administration. |
| GnRH analogs | Discussed in related UpToDate content. | Use of these agents may be considered if the above methods have failed or are contraindicated. |
Hemodynamically unstable patients are typically managed with uterine curettage or high-dose intravenous estrogen. This is discussed in detail separately.
Hemodynamically stable patients who prefer to avoid hormonal therapies or in whom medical therapy is contraindicated or unsuccessful can be managed surgically (eg, endometrial ablation, uterine curettage, uterine artery embolization). This is discussed in related UpToDate content.COC: combined oral contraceptives; GnRH: gonadotropin-releasing hormone; IUD: intrauterine device.
* A table of oral contraceptives is available separately in UpToDate.
¶ Daily dose may be taken at one time or tablets may be separated by several hours to improve tolerability. For patients with moderate bleeding, may start with 3 tablets daily.
Δ May cause weight gain (acts as an appetite stimulant), particularly at higher doses. Dose selection is based on shared decision-making and tolerance of side effects.
◊ Available as 650 mg tablets in the United States. Dosing in Canada, Europe, and elsewhere may vary.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
