Acute heavy menstrual bleeding

Blog Post  by Malcolm G. Munro MD, FACOG, FRCS(c), Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanante, Los Angeles Medical Center, Los Angeles, CA, USA

Recently a young healthy woman presented with acute heavy menstrual bleeding (HMB) and was placed on a multidose combination estrogen-progestin oral contraceptive (COC) regimen. As the bleeding stopped she developed central neurological symptoms and findings and was diagnosed with internal jugular venous thrombosis that resulted in profound neurological sequellae. Investigation identified the presence of a previously undiagnosed case of von Leiden factor deficiency. This case provides a suitable backdrop for discussion about acute heavy uterine bleeding, the role for medical therapy, and the potential consequences of high dose estrogenic interventions.

The entity of acute HMB has only recently been defined as heavy uterine flow not associated with pregnancy that is of sufficient volume to require urgent or emergent medical intervention.¹  Although research evaluating the causes of this recently defined entity is necessary, it is likely that ovulatory disorders (AUB-O) are the most common cause. However, coagulopathies may also contribute (AUB-C), and, particularly in adolescents with von Willebrand disease, may augment the heavy bleeding associated with perimeharcheal anovulation (AUB-C, -O). Arteriovenous malformations are yet another but admittedly rare entity that can also cause acute HMB.