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Menorrhagia Management
Aka: Menorrhagia Management, Ovulatory Bleeding Management, Heavy Menstrual Bleeding Management, Emergent Management of Acute Heavy Uterine Bleeding
- See Also
- Ovulatory Bleeding (Menorrhagia)
- Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding)
- Metrorrhagia Management (Anovulatory Bleeding Management)
- Menstrual Cycle
- Abnormal Uterine Bleeding Causes
- Anovulatory Bleeding (Metrorrhagia)
- Uterine Bleeding in Pregnancy
- First Trimester Bleeding
- Late Pregnancy Bleeding
- Endometrial Cancer Screening
- Oral Contraceptive-Related Uterine Bleeding Management
- Postmenopausal Bleeding
- Amenorrhea
- Lower GI Bleed
- Hematuria
- Management: General
- Suppress Ovulation and Endometrial Thickening
- Progesterone
- Provera 10 mg PO daily on days 5-26 of cycle (21 days per month) OR
- Norethindrone 2.5 to 5 mg orally once daily on days 5-26 of cycle (21 days per month)
- Avoid Luteal Phase only (10 day) - low efficacy
- Combination Oral Contraceptive 1 tab orally daily
- Reduce blood loss by 50% in women with heavy Menstrual Bleeding
- Conventional 28 day cycling
- Loestrin 1.5/30
- High Androgenic Activity
- High Progestational Activity
- Low Estrogenic Activity
- Natazia (Estradiol + Dienogest)
- First Oral Contraceptive FDA approved specifically for Menorrhagia (2012)
- However, expensive and does not offer any additional benefit over Loestrin or other generic OCP
- References
- (2012) Presc Lett 19(5): 27
- Jensen (2011) Obstet Gynecol 117(4):777-87 [PubMed]
- Progestin containing IUD (Mirena): Preferred option
- May reduce blood loss by 90%
- Levonorgestrel IUD is a good Hysterectomy alternative
- Hurskainen (2004) JAMA 291:1456-63 [PubMed]
- Depo-Provera 150mg IM every 11-13 weeks
- Advanced options used in some cases by Gynecology
- Danazol (Danocrine) - Androgenic Steroid
- Dose: 200-400 mg PO qd for 6-9 months
- Androgenic side effects!
- GnRH agonist
- Daily or monthly injection for 4-6 months
- Add back Estrogen
- Therapies that modulate Bleeding Diathesis
- Tranexamic Acid (Lysteda)
- Antifibrinolytic that prevents plasminogen activation
- Oral: Take two 650 mg (or 20-25 mg/kg) tabs orally three times daily for the first 5 days of the cycle
- IV: 10 mg/kg IV every 8 hours
- More effective than NSAIDs
- Initial concern regarding risk of thrombosis, however follow-up studies demonstrated no increased risk
- Correct relative prostaglandin overproduction
- NSAIDs reduce prostaglandin levels via cyclooxygenase inhibition
- Reduce menstrual flow by 20-46%
- Use NSAID for 3-5 days starting with Menses
- NSAID Options
- Mefenamic acid (Ponstel) 500 mg orally three times daily
- Naproxen (Anaprox, Naprosyn) 500 mg orally twice daily
- Ibuprofen 600 mg orally every 6 hours
- Other adjunctive treatment
- Erythropoietin recombinant (not routinely recommended)
- Helps to rapidly correct Anemia
- Endometritis Management
- Doxycycline 100 mg PO bid for 10 days
- Management: Severe or acute Menorrhagia (Hemoglobin <10)
- Monitor for hemodynamic instability
- Consult gynecology early for possible surgical or procedural intervention
- Type and cross for Blood Products
- See Tranexamic Acid (Lysteda) above
- Consult with gynecology if Estrogen protocol started
- Prescribe Antiemetic (e.g. Ondansetron) to any of these protocols (due to high dose Estrogen)
- Estrogen Contraindications (even for brief courses)
- Venous thromboebolism
- Estrogen responsive cancer
- Hospitalization Indication
- Hemoglobin <7 or symptomatic Anemia
- Comorbid conditions
- Estrogen Oral Method
- Initial
- Premarin 2.5 mg PO q6h or 25 mg IV every 4-6 hours
- Antiemetic needed concurrently
- After 12-24 hours
- Premarin 2.5mg PO q6h x5 days
- Provera 10 mg PO qd x5 days (start when bleeding subsides)
- After 5-7 days
- Premarin 2.5 mg PO daily
- Provera 5-10 mg PO daily
- Combination OCP option with
- Contraindications
- See Oral Contraceptives
- Estrogen-dependent tumor
- Venous Thromboembolism or Cerebrovascular Accident
- Active liver disease
- Pregnancy
- Age over 35 years old and Tobacco use >15 Cigarettes daily
- Hypertriglyceridemia
- Preparations
- Use Progestin-dominant OCP with at least 0.030 mg Estrogen
- Norgestrel 0.5 mg and Ethinyl Estradiol 0.05 mg
- Ovral
- Norethindrone 1 mg and Ethinyl Estradiol 0.035 mg
- Ortho Novum 1/35
- Norinyl 1/35
- Necon 1/35
- Dasetta 1/35
- Alyacen 1/35
- Protocol (Prescribe 3 packs)
- Concurrently prescribe Antiemetic
- Take 1 tablet 4 times daily for 2-4 days (until bleeding stops), then
- Take 1 tablet 3 times daily for 3-7 days, then
- Take 1 tablet 2 times daily for 2 days, then
- Take 1 tablet daily for 3 weeks, then
- Skip one week of pills to allow for withdrawal bleeding, and then
- Cycle on Oral Contraceptives for 3 months or more
- Estrogen IV Method
- First
- Premarin 25 mg IV every 4-6 hours (up to every 2 hours) over 30 minutes up to 6 doses
- Next
- Premarin 2.5 mg orally three times daily for 10 days
- Provera 10 mg orally daily for 10 days (start when bleeding subsides)
- Next
- Allow withdrawal bleeding for 5 days
- Next for 3-6 cycles
- Option 1: Oral Contraceptive
- Option 2: Provera 10 mg PO cycle days 5 to 26
- Management: Refractory Uterine Bleeding
- Uterine Foley (For bleeding not controlled by above)
- Foley Catheter inserted into Uterus
- Foley balloon filled with 30 cc of water or saline or until bleeding stops
- Direct Uterine irrigation (For refractory bleeding)
- Uterine irrigation with Aminocaproic Acid (AMICAR)
- Potent Fibrinolysis Inhibitor
- Management: Surgical Management of Uterine Bleeding
- Dilatation and Curettage (D&C)
- Immediately follow with Oral Contraceptive use
- Global Endometrial Ablation (preferred option)
- Older, hysteroscope procedures (first generation)
- Example: Rollerball, Transcervical resection
- Newer, non-hysteroscope procedures (preferred)
- Higher efficacy, lower complication rates
- Examples: Laser, microwave, thermal balloon, cryo
- Hysterectomy (high rate of adverse effects)
- References
- Sowter (2003) Lancet 361:1456-8 [PubMed]
- Management: Vaginal Bleeding (e.g. vaginal Laceration)
- Rectal tube inserted into vagina
- Inflate to tamponade bleeding
- Vaginal packing with gauze
- Risk of infection (Toxic Shock Syndrome)
- Use for brief period to temporize until definitive therapy
- Resources
- NIH Heavy Menstrual Bleeding Assessment and Management
- References
- Mace (2013) Crit Dec Emerg Med 27(2): 13-21
- Nelson (1997), Fam Prac Recert 19(8):14
- (2013) Obstet Gynecol 122(1):176-85 [PubMed]
- Apgar (2007) Am Fam Physician 75(12):1813-20 [PubMed]
- Buchanan (2009) Am Fam Physician 80(10): 1075-88 [PubMed]
- Dilley (2001) Obstet Gynecol 97:630-6 [PubMed]
- Sweet (2012) Am Fam Physician 85(1): 35-43 [PubMed]
- Wouk (2019) Am Fam Physician 99(7): 435-43 [PubMed]
- Sriprasert (2017) Contracept Reprod Med 2:20 +PMID:29201425 [PubMed]