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Managing an episode of acute uterine bleeding

Managing an episode of acute uterine bleeding
Literature review current through: Jan 2024.
This topic last updated: Oct 19, 2023.

INTRODUCTION — An episode of acute (ie, heavy or prolonged) uterine bleeding may occur in reproductive-age patients with either ovulatory or anovulatory bleeding and often results in the need for urgent evaluation in a clinician's office or emergency department. Consequences of such bleeding depend on the volume of bleeding and range from inconvenience to the patient or interference with daily activities, to severe anemia with hypovolemia. Evaluation and management of patients experiencing acute uterine bleeding must be expedited to prevent or treat excessive blood loss.

Evaluation and management of an acute episode of heavy or prolonged uterine bleeding in a reproductive-age patient will be reviewed here. Causes of abnormal uterine bleeding, the evaluation and management of chronic abnormal uterine bleeding, uterine bleeding in pregnancy or in postmenopausal patients, and the approach to patients with a nonuterine source of vaginal bleeding in the emergency department are discussed separately:

(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis" and "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)

(See "Evaluation and differential diagnosis of vaginal bleeding before 20 weeks of gestation".)

(See "Approach to the patient with postmenopausal uterine bleeding".)

(See "Approach to the adult with vaginal bleeding in the emergency department".)

TERMINOLOGY — While there are standard definitions of normal and abnormal menstrual bleeding (table 1), there is no standard definition of acute uterine bleeding. Suggested definitions include:

Excessively heavy or prolonged bleeding of uterine origin sufficient in volume as to require urgent or emergency intervention [1].

Bleeding that is profuse and soaks a large sanitary pad or tampon at every hour or two and continues for two or more hours [2].

While United States regulations specify that each regular to super plus tampon absorbs 6 to 15 g of fluid, which equals approximately 6 to 15 mL of whole blood [3,4], assessing the volume of blood loss by counting tampons or pads appears to be inaccurate. Clinical studies have reported that the absorbency varies greatly for different types of sanitary products and even for products within a single package [5]. For research purposes, the alkaline hematin method is the standard for determining menstrual blood loss from a tampon or sanitary pad; this is discussed in detail separately. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Definitions'.)

In this topic, we will use the term acute to refer to bleeding that is either profuse or prolonged. We also will apply this term to reproductive-age patients with either ovulatory or anovulatory bleeding and those with isolated or recurrent episodes of acute bleeding.

ETIOLOGY — Causes of acute uterine bleeding in nonpregnant patients include anatomic uterine abnormalities (eg, fibroids, arteriovenous malformation), endocrinologic abnormalities (eg, ovulatory or thyroid dysfunction), or bleeding diatheses (figure 1) and are discussed in detail separately. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis" and "Causes of female genital tract bleeding", section on 'Uterine bleeding'.)

CLINICAL PRESENTATION — Patients with acute uterine bleeding generally report bleeding that may soak through clothing or onto bedding. Patients also often report passing blood clots. The current episode may represent either a new onset of bleeding or an exacerbation of existing bleeding; it may be continuous or intermittent. A hiatus of bleeding of several hours may represent blood that has accumulated in the upper vagina and is released when the patient changes position from supine or seated to standing.

Patients may also present with symptoms suggestive of heavy blood loss including feeling dizzy, faint, or having loss of consciousness.

EVALUATION

Initial evaluation of all patients — The goals of the initial evaluation of a patient with acute uterine bleeding are to:

Establish hemodynamic stability – Initial evaluation includes assessment of hemodynamic stability since hemodynamically unstable patients (eg, tachycardic, hypotensive, orthostatic) require immediate supportive measures (eg, blood transfusion) and an expedited assessment (eg, laboratory testing may be performed prior to the history and physical examination; sonographic imaging may be deferred as brisk uterine bleeding may make it difficult to perform or interpret). However, in young healthy patients, vital signs, including postural changes, may be normal early in the course of significant bleeding due to compensatory mechanisms [6].

Exclude pregnancy – The evaluation of pregnant patients with vaginal bleeding is discussed in detail separately. (See "Evaluation and differential diagnosis of vaginal bleeding before 20 weeks of gestation".)

Identify the source of bleeding – The evaluation of patients who present to the emergency department with a nonuterine source of acute vaginal bleeding are discussed in detail separately. (See "Approach to the adult with vaginal bleeding in the emergency department".)

Evaluate the volume of blood loss – On physical examination, the presence and volume of bleeding from the cervical os and blood or blood clots in the vaginal vault is noted. A hemoglobin/hematocrit is sent to assess for anemia and clotting studies are sent in patients with suspected coagulopathy. A bleeding diathesis may be either the etiology of the bleeding or may be secondary to other factors associated with the bleeding. (See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults", section on 'Pathogenesis' and "Evaluation and management of disseminated intravascular coagulation (DIC) in adults", section on 'Diagnostic evaluation'.)

Further evaluation of hemodynamically stable patients — Further evaluation of hemodynamically stable patients includes the following:

History and physical examination – A complete history and physical examination is performed to confirm the uterus is the source of, and identify possible etiologies of, the bleeding. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'History' and "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Physical examination'.)

Additional laboratories – In addition to the above laboratories, a serum thyroid-stimulating hormone (TSH) level should be performed if thyroid disease is suspected. (See 'Initial evaluation of all patients' above and "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Heavy menstrual bleeding'.)

Identify structural abnormalities – Uterine structural abnormalities can be identified with pelvic examination and/or pelvic imaging. Pelvic ultrasound is the imaging study of choice as it can be performed quickly, is relatively inexpensive, and is a sensitive method for detecting uterine pathology. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Imaging: Choice of modality'.)

Evaluation of the endometrium – Evaluation of the endometrium (typically with endometrial sampling) should be performed in select nonpregnant reproductive-aged patients and all postmenopausal patients who have an episode of acute uterine bleeding (table 2), to exclude endometrial hyperplasia/neoplasia or, less commonly, endometritis. Whether sampling is performed before, during, or after treatment depends on the choice of initial therapy (ie, uterine curettage is both diagnostic and therapeutic) and whether the patient's hemodynamic status allows therapy to be deferred while sampling is performed. It is preferable to collect an endometrial specimen prior to hormonal therapy whenever possible, since hormonal alterations may interfere with interpretation of the sample. (See "Endometrial sampling procedures".)

MANAGING HEMODYNAMICALLY UNSTABLE PATIENTS — Hemodynamically unstable patients with acute uterine bleeding require immediate intervention (algorithm 1). Such patients who present to an ambulatory setting should be transferred immediately to an acute care setting.

Stabilizing the patient — Patients with hemodynamic instability require vascular access and blood product replacement (table 3A-B). Intravenous (IV) fluids may be given to hypotensive patients but are generally avoided in patients with hemorrhage given the increased risk of coagulopathy from dilution of clotting factors and platelets. This is discussed in detail separately. (See "Indications and hemoglobin thresholds for RBC transfusion in adults" and "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Initial management of hemorrhage'.)

Therapeutic measures

Preferred: Uterine curettage — For hemodynamically unstable patients with acute uterine bleeding, uterine curettage is the treatment of choice. One exception is patients with an arteriovenous (AV) malformation of the uterus; these patients may be managed differently. (See 'Role of uterine artery embolization' below.)

In most patients and at most institutions, uterine curettage can be performed rapidly, with cessation or significant decrease in bleeding in less than one hour. Other advantages of uterine curettage are that it is both diagnostic and therapeutic and it can be performed in patients who may desire future childbearing. A disadvantage of curettage is that it does not treat the underlying cause of uterine bleeding, so bleeding is likely to recur if no preventive therapy is initiated postoperatively [7,8].

There are no high-quality data comparing uterine curettage with medical therapy in patients with acute uterine bleeding. According to indirect data and clinical experience, medical therapy requires more time until bleeding subsides, but avoids the risk of perioperative complications [7]. Medical therapy is often beneficial in addition to curettage if bleeding persists after the procedure or to prevent recurrent bleeding. (See 'Alternative: High-dose intravenous estrogen' below.)

When curettage is performed, it can be done using a standard dilation and curettage (D&C) or a Karman cannula. Advantages of the Karman cannula are that it can be used in the office or emergency department and often does not require cervical dilation. However, the Karman procedure typically removes less tissue and, thus, it may be less effective at decreasing bleeding. The steps of each procedure are discussed in detail separately. (See "Endometrial sampling procedures" and "Dilation and curettage".)

Role of intrauterine tamponade — Intrauterine tamponade may be used in conjunction with administration of blood products to stabilize the patient while more definitive therapy (eg, transfer to a high-acuity setting, preparation for uterine curettage, arrival of a surgeon) is implemented, or after completion of uterine curettage should bleeding continue.

Intrauterine tamponade can be achieved using either an intrauterine balloon or gauze packing. The steps for placing either of these are:

Place a speculum in the vagina and visualize the cervical os.

Sterilize the cervix by swabbing it three times with a large cotton swab or gauze soaked in iodine.

Stabilize the cervix by placing a single-tooth tenaculum or ring forceps on the anterior cervical lip.

Grasp the balloon or gauze with a long Kelly or ring forceps and thread it in through the cervical os into the uterus.

When a balloon is used, it is inflated after it is inserted into the uterus. A 30 mL Foley catheter is typically used; if brisk bleeding continues and the uterus is enlarged (eg, equivalent to ≥12 weeks of gestation), a larger balloon (eg, Bakri Cook balloon with a 500 mL capacity (figure 2)) may be required but should be avoided in adolescent patients [9]. Other balloons are available but have almost exclusively been used in patients with postpartum hemorrhage; thus, experience in nonpregnant patients is limited. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Intrauterine balloon tamponade'.)

When gauze is used, a continuous piece of gauze (eg, Kerlix) is preferred over smaller gauze pieces to avoid retained pieces of gauze upon removal. Specialized hemostatic gauze may also be used and is described separately (see "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Intrauterine packing'). Gauze is placed until no further gauze can be admitted. Firm, but not excessive, pressure is used to avoid uterine perforation. The gauze can be impregnated with 5000 units thrombin in 5 mL sterile saline to enhance clotting. If packing does not control hemorrhage, in our clinical experience, repacking is unlikely to be effective.

The distended tamponaded uterus causes discomfort, which can be treated with analgesics or a slight reduction in distending pressure, as long as tamponade is maintained. Devices used to tamponade the uterus should not be left in place for more than 24 hours. If the tamponade is not removed for the purpose of other treatment measures, then deflation is performed slowly (eg, removal of 20 mL/hour for a balloon or removal of 5 cm/hour for gauze). We give broad-spectrum antibiotics for infection prophylaxis to patients with an intrauterine balloon or packing in place. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Postplacement care'.)

This technique is generally similar to that of intrauterine tamponade in a postpartum patient with hemorrhage, which is discussed in detail separately. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device".)

Alternative: High-dose intravenous estrogen — For hemodynamically unstable patients with acute uterine bleeding in whom a waiting period of three or more hours is not likely to result in the need for additional blood product transfusion or medical complications, we suggest medical therapy with high-dose IV conjugated equine estrogen (CEE) therapy. This therapy should be avoided in patients with absolute contraindications to estrogen therapy. (See 'Patients at risk of thrombosis' below.)

The American College of Obstetricians and Gynecologists (ACOG) recommends CEE 25 mg intravenously every four to six hours, for 24 hours [10]. The minimum effective dose should be administered to minimize side effects (eg, emesis) and risk of complications (eg, venous thromboembolism [11]). IV estrogen appears to result in cessation of bleeding in most patients within five hours of the first dose by promoting rapid regrowth of the denuded endometrium, stabilizing lysosomal membranes, and stimulating proliferation of endometrial ground substance [7]. In a randomized trial including 34 patients with excessive or prolonged uterine bleeding, more patients receiving IV CEE (Premarin 25 mg in 5 mL isotonic saline injected over two minutes with a dose repeated at three and five hours from the initial dose if bleeding continued) compared with placebo (lactose 200 mg) experienced cessation of bleeding after five hours of the first dose (72 versus 38 percent, respectively); at three hours bleeding cessation rates were similar between groups [12]. Among the five patients in the CEE group with continued bleeding at five hours, bleeding persisted in two patients at eight hours. Endometrial biopsy revealed no association between histology (ie, benign, neoplasia, endometritis) and success of therapy.

An antiemetic is often required with this regimen. We give prochlorperazine IV 2.5 to 10 mg every three to four hours as needed, with a maximum dose of 40 mg/day. In the trial described above, IV CEE produced nausea and vomiting in 39 percent of treated patients compared with 13 percent in the placebo group [12].

If bleeding does not subside after eight hours, IV estrogen should be stopped and other treatments (eg, uterine curettage) employed [12]. If bleeding subsides, IV estrogen is continued for a total of 24 hours, and then an oral regimen (typically a combined oral contraceptive taper) is prescribed. (See 'Preferred: High-dose combined oral contraceptives' below and 'High-dose oral estrogen' below.)

Subsequent line — For patients with continued bleeding despite treatment with first line or alternate therapies, uterine artery embolization (UAE) or tranexamic acid may be used. (See 'Role of uterine artery embolization' below and 'Tranexamic acid' below.)

Last line: Hysterectomy — In the rare case in which the above measures fail, hysterectomy is a last resort. (See "Hysterectomy: Abdominal (open) route", section on 'Emergency or unplanned hysterectomy'.)

MANAGING HEMODYNAMICALLY STABLE PATIENTS — Acute uterine bleeding in hemodynamically stable patients is usually self-limited. In such cases, immediate treatment is often not required, and a complete evaluation can be completed prior to starting treatment. (See 'Further evaluation of hemodynamically stable patients' above and "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

Preferred: High-dose combined oral contraceptives — For hemodynamically stable patients with acute uterine bleeding and no contraindications to estrogen therapy (see 'Patients at risk of thrombosis' below), and in whom a waiting period of 48 hours is not likely to result in additional medical complications, we use high doses of oral contraceptives (OCs) (algorithm 2 and table 4).

We use a tapering regimen (eg, 35 mcg ethinyl estradiol-containing combination OC pill; five pills on day 1, four pills on day 2, three pills on day 3, two pills on day 4, and one pill on day 5); use of other formulations (eg, 30 and 50 mcg ethinyl estradiol-containing pills) and tapers have been described [1,13]. In most patients, bleeding will subside within 48 hours [1,14]. For patients with moderate bleeding, we start with three pills daily. To improve tolerability, the pills may be taken several hours apart and an antiemetic medication (eg, promethazine 12.5 to 25 mg per rectum) should be prescribed.

Treatment with one pill daily (omitting inactive [placebo] tablets) of the OC should continue for one to three weeks after the bleeding subsides and then should be stopped for three to five days to allow for a withdrawal bleed. Standard-dose OCs may then be restarted, either as a monthly or extended cycle regimen, to prevent recurrent menorrhagia or for contraception.

Other combined estrogen-progestin contraceptives (vaginal ring, patch) are not used for treatment of an episode of acute uterine bleeding since it is not possible to vary the dose as precisely as with OCs.

There are no data comparing treatment of estrogen-progestins with estrogen alone in patients with acute uterine bleeding. As discussed below (see 'High-dose oral estrogen' below), physiologically it appears that treatment with estrogen alone is likely to be effective more rapidly than with a combined estrogen-progestin; however, some patients prefer OCs due to familiarity or other reasons.

Alternatives —  (algorithm 2 and table 4)

High-dose oral estrogen — High-dose oral estrogen is an alternative to high-dose combined OCs and may be used in patients without contraindications to estrogen therapy in whom a waiting period of 48 hours is not acceptable, or those who prefer to avoid OCs. We give conjugated equine estrogen 2.5 mg every six hours [15]. This dose is equivalent to 8 to 40 mcg of ethinyl estradiol [16] and is therefore similar to or less than one dose of a 35 mcg OC. When bleeding subsides or is minimal, the dose may be decreased to 2.5 mg orally twice daily. Total duration of use is 21 to 25 days. Many patients experience nausea and vomiting while taking high-dose estrogen. An antiemetic (eg, promethazine 12.5 to 25 mg per rectum) should be prescribed, to be used as needed [14].

There are no data regarding the time course of therapeutic success with high-dose oral estrogen. Based on the data for intravenous (IV) estrogen therapy and allowing for a delayed onset of action with oral administration, bleeding is likely to stop in most patients within 10 hours after the first dose. (See 'Alternative: High-dose intravenous estrogen' above.)

After the estrogen is discontinued, a progestin should be given; we use oral medroxyprogesterone acetate (10 mg/day) for 10 days. Administration of progestin concomitantly with estrogen for the last 7 to 10 days also been described [17].

Estrogen therapy alone may be more effective than combined estrogen-progestin or progestin-alone therapy because progestins inhibit the synthesis of estrogen receptors and increase estradiol dehydrogenase, thereby impeding the rapid proliferation of endometrium induced by estrogen. (See 'Preferred: High-dose combined oral contraceptives' above.)

Oral progestins — For hemodynamically stable patients in whom the suspected etiology of acute bleeding is from anovulation, progestins rather than high-dose estrogen may be used as first line therapy. In such patients with a thickened endometrium, progestins inhibit further endometrial growth and organize and support the estrogen-primed endometrium, allowing effective sloughing upon hormone withdrawal [7]. By contrast, if acute bleeding has resulted in a denuded endometrium, progestins are unlikely to be effective. Diagnosis of anovulation is discussed separately.

In our practice, we use medroxyprogesterone acetate (MPA; 20 mg three times daily), but other dosing (eg, MPA 10 mg three times daily) and progestins (eg, megestrol acetate 20 to 60 mg two times daily; norethindrone 5 mg once to four times daily) have been described [1,13,18,19]. Dose selection is based on shared decision-making and tolerance of side effects. 

Progestins are typically continued for at least 5 to 10 days. In anemic patients who can tolerate this regimen, a one- to two-month treatment period in conjunction with iron allows an increase in hemoglobin/hematocrit (see "Treatment of iron deficiency anemia in adults", section on 'Response to iron supplementation'). Prolonged use of these drugs can cause acne, mood changes, weight gain, headache, and lipid abnormalities.

In a randomized trial including 40 patients with acute uterine bleeding, treatment with medroxyprogesterone acetate (20 mg three times daily for seven days) compared with combined estrogen-progestin therapy (ethinyl estradiol 35 mcg and norethindrone 1 mg three times daily for seven days) resulted in cessation of bleeding in approximately three days in both groups [1]. To our knowledge, no trials have compared megestrol acetate with combined estrogen-progestin therapy or MPA for this indication.

Surgical management — For hemodynamically stable patients who prefer to avoid hormonal therapies or in whom medical therapy is contraindicated or unsuccessful, surgical management (ie, endometrial ablation, uterine curettage, uterine artery embolization [UAE]) may be performed; hysterectomy is reserved for patients who strongly desire definitive surgical management. We prefer endometrial ablation rather than uterine curettage or UAE in patients in whom malignancy has been excluded and in those who have completed future childbearing. Endometrial ablation is an effective alternative treatment [20-24], and is more likely to provide long-term improvement in uterine bleeding symptoms, compared with other minimally invasive surgical therapies. An exception is patients in whom future childbearing is desired. In such patients, curettage is preferred as pregnancy is contraindicated following endometrial ablation and the safety of pregnancy following UAE is uncertain. If ablation is performed, patients must be counseled that contraception will be necessary following the procedure. (See 'Preferred: Uterine curettage' above and 'Role of uterine artery embolization' below.)

Hysteroscopy prior to ablation may be useful to identify and treat endometrial polyps or intracavitary leiomyomas. (See "Overview of endometrial ablation".)

The potential efficacy of endometrial ablation was illustrated in a report of 26 patients with acute uterine bleeding who underwent ablation [20]. At one-year follow-up, 25 of 26 patients reported decreased bleeding and did not require further medical or surgical therapy; one patient required a hysterectomy after 16 months in the setting of a leiomyoma and persistent uterine bleeding. The efficacy of endometrial ablation in other patients (ie, patients with heavy menstrual bleeding) are discussed elsewhere. (See "Overview of endometrial ablation", section on 'Outcomes'.)

Subsequent line —  (table 4)

Gonadotropin-releasing hormone analogs — Gonadotropin-releasing hormone (GnRH) analogs, including agonists and antagonists, can be used in the treatment of acute uterine bleeding but are not first-line treatments. They are used more commonly as second- or third-line therapy to prevent abnormal uterine bleeding or as a temporizing measure until surgical intervention can be performed. Their use is limited by expense and adverse effects. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)

GnRH agonists – There are few reports of GnRH agonists for treatment of an acute episode of uterine bleeding [17,25]. Use of these agents may be considered in this setting if other methods have failed or are contraindicated. If they are used, they result in an initial follicle-stimulating hormone and luteinizing hormone surge that can lead to an increased volume of bleeding. Use of GnRH agonists in combination with other agents (eg, OCs) may avoid this surge. However, because of the potential for increased bleeding initially, GnRH agents should be used only in patients who can tolerate several days of heavy uterine bleeding. In our experience, treatment with GnRH agonists results in a decrease in the volume of bleeding within one week.

GnRH antagonists – GnRH antagonists are a relatively new generation of drug therapy, and, unlike GnRH agonists, a surge in gonadotropins is not observed. Two of these drugs, elagolix and relugolix, have been shown to reduce heavy menstrual bleeding associated with uterine fibroids [26,27]. This is discussed in more detail separately (see "Uterine fibroids (leiomyomas): Treatment overview", section on 'GnRH analogs'). However, use of GnRH antagonists for treatment of an acute episode of uterine bleeding has not yet been reported.

Tranexamic acid — Another medical therapy option is tranexamic acid (eg, 1.3 g orally three times daily for up to five days), which acts within two to three hours of administration [13,28]. The drug exerts an antifibrinolytic effect by reversibly blocking lysine binding sites on plasminogen, thereby preventing fibrin degradation. Side effects from tranexamic acid include nausea, dizziness, and diarrhea.

Tranexamic acid was approved by the US Food and Drug Administration in 2009 for treatment of menorrhagia [29]. The risk of thrombotic events with tranexamic acid is controversial [30-36]. We use tranexamic acid only when other options have been unsuccessful and only in patients who are not at a high risk of thrombosis. It therefore has limited use in patients with contraindications to hormonal therapy since these are mainly due to risk of thrombosis. (See 'Patients at risk of thrombosis' below.)

While tranexamic acid may be used to reduce blood loss during open myomectomy, its use to stop excessive uterine bleeding in the outpatient setting appears to be limited [37]. The American College of Obstetricians and Gynecologists (ACOG) guidelines mention using IV tranexamic acid at a dose of 10 mg/kg (maximum 600 mg/dose) every eight hours [10].

SPECIAL CONSIDERATIONS

Role of uterine artery embolization — For patients in whom the suspected etiology of acute bleeding is from a uterine arteriovenous (AV) malformation, uterine artery embolization (UAE) rather than uterine curettage may be used as first line therapy since it is an effective treatment for this condition. UAE can also be used as an effective alternative to hysterectomy in patients who wish to preserve their uterus.

Use of UAE in hemodynamically unstable patients is otherwise limited because it usually cannot be performed as rapidly as other measures.

The safety of pregnancy after UAE is uncertain and may be associated with adverse outcomes (eg, miscarriage, preterm birth, placental problems, malpresentation) in some pregnancies. This is discussed in detail separately. (See "Uterine fibroids (leiomyomas): Treatment with uterine artery embolization", section on 'Reproductive outcomes'.)

Patients at risk of thrombosis — Potential complications of estrogen therapy include venous thromboembolism (VTE) and coronary or cerebral thrombosis. Thus, estrogen therapy is contraindicated in patients at high risk for such complications (table 5). (See "Menopausal hormone therapy: Benefits and risks" and "Overview of the causes of venous thrombosis".)

By contrast, some patients with relative contraindications to estrogen therapy can be safely treated with estrogen for a short period (ie, ≤4 weeks), including those without vascular or thrombotic complications but with the following conditions (this list is not comprehensive):

Hypertension

Diabetes

Systemic lupus erythematosus

Smoking

For patients in whom it is uncertain whether short-term estrogen therapy is safe, their primary care clinician should be consulted before initiating therapy. All patients should be counseled about the potential risks of estrogen therapy and instructed regarding warning signs of potential thrombotic events (eg, asymmetric swelling of an extremity, chest pain, shortness of breath) and monitored closely for these symptoms.

Large epidemiologic studies have not identified an increased risk of stroke, myocardial infarction, or VTE with use of progestin-only contraceptives. However, norethindrone acetate can be converted in the body to ethinyl estradiol, so use of this progestin should be avoided in high-risk patients [38]. The risk of thrombotic events with tranexamic acid is controversial. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk' and 'Tranexamic acid' above.)

Patients who are not candidates for hormonal or tranexamic acid therapy are treated surgically (see 'Preferred: Uterine curettage' above and 'Surgical management' above and 'Role of uterine artery embolization' above). Such patients who are also on anticoagulant therapy require appropriate perioperative management of these medications. (See "Perioperative management of patients receiving anticoagulants".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abnormal uterine bleeding".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Heavy periods (The Basics)")

Beyond the Basics topics (see "Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Terminology – Acute uterine bleeding is excessively heavy or prolonged bleeding of uterine origin sufficient in volume to require urgent or emergency intervention. It may occur in reproductive-age patients with ovulatory or anovulatory bleeding and be an isolated episode or recurrent. (See 'Terminology' above.)

Goals of evaluation – The goals of evaluation of patients who present with acute bleeding are to establish hemodynamic stability, exclude pregnancy, identify the source of bleeding, and evaluate whether the bleeding requires immediate medical and/or surgical treatment. (See 'Evaluation' above.)

Endometrial sampling – Endometrial sampling is performed in select nonpregnant reproductive-age patients and all postmenopausal patients with acute uterine bleeding to exclude endometrial hyperplasia/neoplasia (table 2). Whether sampling is performed before, during, or after treatment depends on the choice of initial therapy and whether the patient's hemodynamic status allows therapy to be deferred while sampling is performed. (See 'Further evaluation of hemodynamically stable patients' above.)

Hemodynamically unstable patients – For hemodynamically unstable patients with acute uterine bleeding (algorithm 1):

Initial stabilization includes obtaining vascular access and blood product replacement. (See 'Stabilizing the patient' above.)

For most patients, we suggest uterine curettage rather than medical therapy (Grade 2C). Uterine curettage can be performed rapidly and is both diagnostic and therapeutic (cessation or decreased bleeding is expected in less than one hour). Patients with a suspected uterine arteriovenous malformation may be managed differently. (See 'Preferred: Uterine curettage' above and 'Role of uterine artery embolization' above.)

Intrauterine tamponade may be used in conjunction with administration of blood products while more definitive therapy (eg, transfer to a high-acuity setting, preparation for uterine curettage, arrival of a surgeon) is implemented, or after completion of uterine curettage should bleeding continue. (See 'Role of intrauterine tamponade' above.)

For patients with persistent bleeding after uterine curettage or prevention of recurrent bleeding, or for those in whom a waiting period of three or more hours is not likely to result in the need for additional blood product transfusion or medical complications, we suggest intravenous conjugated equine estrogens (CEE) alone rather than other medical or surgical therapy (Grade 2C). (See 'Alternative: High-dose intravenous estrogen' above.)

Hysterectomy is reserved for patients in whom all other treatments are unsuccessful. (See 'Last line: Hysterectomy' above.)

Hemodynamically stable patients (algorithm 2 and table 4)

For hemodynamically stable patients with acute uterine bleeding we suggest high-dose combined oral contraceptives (OCs) rather than treatment with high-dose oral estrogens alone, progestins, or tranexamic acid (Grade 2C). However, OCs compared with oral estrogen alone may take longer to be effective. Other reasonable alternatives include progestin therapy for patients with anovulatory bleeding and a thickened endometrium or high-dose oral estrogen for those who prefer to avoid OCs. (See 'Preferred: High-dose combined oral contraceptives' above.)

For patients in whom medical therapy is contraindicated or unsuccessful, we suggest endometrial ablation rather than uterine curettage or uterine artery embolization (UAE (Grade 2C)). However, ablation should only be performed in patients in whom malignancy has been excluded and in those who have completed childbearing. For patients who have not completed childbearing, uterine curettage is preferred. (See 'Surgical management' above.)

Patients at high risk for thrombosis – Estrogen therapy and tranexamic acid are contraindicated in patients at a high risk of thrombosis (table 5). In such patients, we suggest treatment with progestins or surgery (Grade 2C). (See 'Patients at risk of thrombosis' above.)

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Topic 5415 Version 41.0

References

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