Acute heavy menstrual bleeding
March 28, 2011 1 Comment
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.
The management of acute AUB/HMB frequently requires utilization of urgent care, emergency, and/or operating room resources to control the bleeding. Fortunately, there exist a number of nonsurgical approaches that may control the acute problem without the need for operative intervention that include administration of gonadal steroids, and intrauterine tamponade. Parenteral conjugated estrogens have been demonstrated effective in one randomized trial2 and the COC “taper” has been evaluated and found effective in a trial from our institution – a trial, that, surprisingly is the only published study on this approach.3 However, these high doses of estrogens have the potential to “uncover” women with hypercoagulable states such as excess Factor VIIIc or von Willebrand factor, or the presence of Factor V von Leiden an entity that may affect up to 5% of the female population.4 As a result, alternative approaches to the problem of acute HMB are desirable.
Orally administered progestins should not impact coagulation and are an option that has been previously published in a little known study5, We demonstrated equivalence of moderate dose medroxyprogesterone acetate to a monophasic COC protocol in a pilot randomized trial.3 Another approach is to avoid gonadal steroids altogether using an inflated intracavitary Foley catheter balloon to achieve endometrial tamponade.6 There may be other effective agents, such as tranexamic acid, but, to date, there have been no published trials. These and other approaches are discussed in my book, “Abnormal Uterine Bleeding” published by Cambridge Medical Press.7 Regardless, further research on this little-investigated entity is urgently needed.
1. Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. Apr 2011;113(1):3-13.
3. Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. Oct 2006;108(4):924-929.
4. Ohira T, Cushman M, Tsai MY, et al. ABO blood group, other risk factors and incidence of venous thromboembolism: the Longitudinal Investigation of Thromboembolism Etiology (LITE). J Thromb Haemost. Jul 2007;5(7):1455-1461.
5. Aksu F, Madazli R, Budak E, Cepni I, Benian A. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust N Z J Obstet Gynaecol. May 1997;37(2):228-231.
6. Goldrath MH. Uterine tamponade for the control of acute uterine bleeding. Am J Obstet Gynecol. Dec 15 1983;147(8):869-872.
7. Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press; 2010.