Latebreakers

Question:

I am used to treating patients who report chronic heavy menstrual bleeding, but what can I do for a patient in my clinic who at this moment is actively losing excessive amounts of blood? She has to change her pad every 30-40 minutes and wear double protection to prevent spillage. I can tell she needs help now and may not be able to be referred.

Answer:

Acute heavy menstrual bleeding is most often seen in Emergency Room settings. Sometimes women actually delay their clinic visits because of acute bleeding. The pain and challenges pose to traveling and maintaining personal hygiene. Regardless of where you see her – In your office, in an urgent care setting, even in an ER, the initial work-up is the same, advises Anita Nelson, MD.

• Determine that she is hemodynamically stable. Check her symptoms and vital signs (are there any orthostatic changes?).
• Rule out pregnancy with a urine pregnancy test.
• Measure a hemoglobin/hematocrit to rule out anemia. A HBG > 8 mg/L is needed for outpatient management.
• Ask about medication she may be taking, particularly anticoagulants.
• Obtain a complete menstrual history, including past episodes, past work-ups and past treatments and their effectiveness. Any prior cancers.
• Perform a targeted exam starting with an abdominal exam to rule out enlarged, irregularly shaped uterus.
• Pelvic exam would follow. In particular, rule out more unusual causes of acute bleeding, like aborting fibroid, trauma, known carcinoma, foreign body.

Having ruled out conditions that may require immediate procedures, the good news is that most episodes of acute excessive bleeding will respond very well to hormonal therapies. As you select the best to use, it helps to remember that the treatment must not only be able to safely stop the immediate bleeding, but also to prevent any more bleeding for 4 weeks. This time is needed for the patient to rebuild her hemoglobin and for the provider to obtain the results of any tests that were performed to help diagnose the cause of the abnormal bleeding so more targeted long-term plans can be designed.

The most effective, safe, and well-tolerated treatment that achieves these goals relies on high-dose progestin. Medroxyprogesterone acetate (MPA) 20 mg by mouth 3 times a day for 7 days, followed by MPA 20 mg orally once a day for 3 more months. This progestin-only treatment stops bleeding rapidly and effectively and usually induces amenorrhea for at least 28 days. This regimen does not contain any estrogen. Also, MPA is not metabolized into estrogen the way other progestins (e.g., norethindrone acetate) are. This means that the estrogen-induced risk of thromboembolism is minimized. Studies show that this high-dose treatment is also well-tolerated. Protocols that call for shorter-term or lower-dose progestin are more frequently offered, but they are not supported by evidence, and they often fail to achieve both treatment goals. Most commonly, MPA 10 mg by mouth daily for 10 days is recommended, but it often causes repeat bleeding within 3 days of cessation.

In some settings, estrogen-containing oral contraceptives are used. If these are used, it is important to avoid excessively high doses and rapid “tapering” that result in rebleeding shortly after the treatment ends.

Any pill with 1 mg norethindrone and 35 mcg ethinyl estradiol (EE) can be used in either of these regimens.

• 1/35 pill with norethindrone and EE given orally, 3 times a day for 7 days, followed by a 1/20 norethindrone and EE pill once a day for the next 21 days.

OR

• 1/35 pill with norethindrone and EE given orally every 12 hours for 2 doses, followed by 1 pill daily for the rest of the pill packet.

There is no need to use higher doses of oral contraceptives initially, as it increases VTE risk. Similarly, more rapid “tapering” can induce repeat abnormal bleeding. The first option was tested and published against the MPA-only protocol. The single day, higher dose with normal dose for the subsequent 26 days was recommended in recent textbooks.

It should be noted that these treatments have only been tested in hemodynamically stable women who are eligible for outpatient care. The data supporting medical hormonal treatment for those whose bleeding requires hospitalization is less well supported. Both combined oral contraceptives and intravenous estrogen alone or consecutively have been recommended. More research is clearly needed for these women.