Check options for acute uterine bleeding
Results from a recently published study suggest that combination oral contraceptives (OCs) and oral medroxyprogesterone acetate (MPA) may be effective treatment options for acute uterine bleeding.1
In nonpregnant women, acute uterine bleeding can be defined as excessive or prolonged bleeding that calls for urgent or emergent intervention.1 Acute uterine bleeding usually reflects anovulation, either as an isolated event in an otherwise ovulatory woman or in the context of chronic anovulatory uterine bleeding. In these instances, when evaluation of the patient reveals no other etiologies such as trauma, cancer, or coagulopathy, it is essentially a form of dysfunctional uterine bleeding and may comprise about 10% of cases of dysfunctional uterine bleeding.2
Women who present with acute uterine bleeding often are hospitalized for surgical intervention, and are typically treated with dilation and curettage, although occasionally endometrial ablation, uterine artery embolization, or hysterectomy are performed.
Medical management of acute uterine bleeding can be achieved by use of high-dose, intravenous estrogen. In a small randomized, double blind, placebo-controlled trial, bleeding was stopped within five hours in 72% of patients who received intravenous conjugated equine estrogens and in 38% who received placebo.3
Other treatment approaches for acute uterine bleeding have included use of multidose combined OC regimens; however, support for their use has been based on textbooks and expert opinion, with no previous published research conducted with such agents, notes Malcolm Munro, MD, professor of obstetrics and gynecology in the David Geffen School of Medicine at the University of California Los Angeles and chair of the Abnormal Uterine Bleeding Working Group for the Kaiser Permanente Southern California, Los Angeles. A single report has been published on use of progestins alone for the treatment of nongestational, acute uterine bleeding,4 states Munro, who served as lead investigator for the currently published research. In the study using progestin alone, patients were given 60-120 mg of oral medroxyprogesterone acetate on the first day, followed by 20 mg per day to a total of 10 days. All of the patients stopped bleeding within four days.4
Review the research
To perform the current study, Munro and research colleagues enrolled 40 women who had acute uterine bleeding sufficient to warrant immediate medical or surgical intervention. The women were randomized in the open label trial to a monophasic OC containing 35 mcg of ethinyl estradiol and 1 mg norethindrone or to 20 mg of oral MPA. The MPA was taken three times a day, with dosing reduced to once per day after a week and continued for 28 days.
In the 33 patients evaluated at 14 and 28 days, all of those in the MPA group and 95% of the OC group avoided emergency surgery. At a median of three days after the start of treatment, bleeding stopped in 88% of the OC group and 76% of the MPA group. Compliance with therapy was higher in the medroxyprogesterone acetate group than the OC group, but there was no overall difference in the incidence of treatment-related nausea and bloating, the scientists report.1 While the randomized trial was limited by sample size, its findings suggest that both regimens may be effective and reasonably well tolerated, they conclude.1
Look for future publication of the first acute uterine bleeding guidelines through the Agency for Healthcare Research and Quality's National Guideline Clearinghouse web site (www.guideline.gov), says Munro. The web site serves as a public resource for evidence-based clinical practice guidelines.
Munro, a member of the attending staff of Kaiser Permanente Southern California Los Angeles Medical Center, says the guidelines, based on evidence developed through the managed care organization, should help to clarify treatment options for acute uterine bleeding.
More research is needed, says Munro. "We have some interest in getting a number of sites together to do a randomized trial that is multicenter and potentially involving other agents, other doses, or other regimens," he states.
References
- Munro MG. Medical management of abnormal uterine bleeding. Obstet Gynecol Clin North Am 2000; 27:287-304.
- Singh RH, Blumenthal P. Hormonal management of abnormal uterine bleeding. Clin Obstet Gynecol 2005; 48:337-352.
- DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding — a double blind randomized control study. Obstet Gynecol 1982; 59:285-291.
- Aksu F, Madazli R, Budak E, et al. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust NZ J Obstet Gynaecol 1997; 37:228-231.
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