II. Approach
- See Abnormal Uterine Bleeding
-
General
- Pregnancy Test (bHCG) in all patients
- Sexually Transmitted Infection (STI) screening as indicated
- Cervical Cancer Screening (e.g. Pap Smear) if not up to date
-
Hormonal Contraception related uterine bleeding
- Evaluate for Contraception compliance and missed doses (consider reminder apps and other tools)
- Evaluate for other hormonal agents
- Evaluate for Drug Interactions that alter Estrogen metabolism
III. Causes: Hormonal Contraception
-
Levonorgestrel IUD (e.g. Mirena, Liletta, Kyleena, Skyla)
- Associated with prolonged bleeding in first 3 months
- Bleeding decreases in the first 12 months in 90% of patients
- Up to 20% will have Amenorrhea within 12 months
-
Progesterone Implant (e.g. Nexplanon, Implanon)
- Frequent or prolonged bleeding occurs in 23% of patients (unlike IUD, often persists)
-
Depo Provera (DMPA)
- Associated with prolonged Menses in 26% in first 3 months of use, but improves with continued use
- Abnormal Uterine Bleeding resolves in 85% of patients within first 12 months
-
Oral Contraceptives
- See Oral Contraceptive-Related Uterine Bleeding Management
- Most common cause of mid-cycle bleeding
- Abnormal Uterine Bleeding occurs in up to 50% of patients in first 3-6 months (10% afterward)
IV. Causes: General
- Anticoagulants and antiplatelet agents
- Endocrine agents
- See Hormonal Contraception as above
- Corticosteroids
- Estrogen Replacement Therapy or Herbal Estrogen
- Tamoxifen
- Herbal supplements
- Ginseng
- Ginkgo
- Soy Protein
- Neuropsychiatric agents
- Miscellaneous