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Emergency Department Management of Abnormal Uterine Bleeding in the Nonpregnant Patient
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Publication Date: August 2021 (Volume 23, Number 8)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 08/01/2024.

Author

Tazeen Abbas, MD
Emergency Department, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, NY
Abbas Husain, MD, FACEP
Associate Program Director, Emergency Medicine, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, NY

Peer Reviewers

Jacob Arnold, MD
Assistant Professor of Emergency Medicine, Uniformed Services University of the Health Sciences; Emergency Medicine Physician, Martin Army Community Hospital, Fort Benning, GA
Ashley Booth Norse, MD, FACEP
Associate Chair of Operations, Associate Professor, Department of Emergency Medicine, University of Florida College of Medicine Jacksonville, Jacksonville, FL

Abstract

Uterine bleeding that is abnormal in timing, duration, or quantity affects nearly one-third of women and carries a substantial financial and quality-of-life burden. An estimated 5% of ED visits are for vaginal bleeding, and 1% of those patients will have a life-threatening cause that must be identified. Emergency clinicians need to have a comprehensive understanding of the pathophysiology and etiologies of abnormal uterine bleeding to manage and treat these patients. This issue reviews the most recent updates on common causes and the approach to abnormal uterine bleeding in the nonpregnant patient, including vaginal bleeding in prepubescent females.

Case Presentations

CASE 1
A 29-year-old woman presents with vaginal bleeding for 3 weeks…
  • The patient states that she has been unable to get an appointment with her gynecologist until the end of the week, and she is concerned over the increasing blood loss. She has a history of irregular menstrual periods, and she was having intermittent spotting that has become heavier, with clots, over the past 5 days. She is using multiple pads a day.
  • In triage, her vital signs are within normal limits. You order a pregnancy test, which is negative.
  • You wonder whether and how you should begin treatment, or whether you should do nothing and defer to her gynecologist…
CASE 2
The red phone in the ED rings with a prenotification that an 18-year-old woman with active, profuse vaginal bleeding for the past 4 hours is on her way…
  • EMS says that the patient appears pale and weak, and she is tachycardic and hypotensive. They said the patient told them that she had begun spotting 1 week prior, but the bleeding had become acutely worse. EMS also notes that the patient told them that she had a nosebleed a few days ago.
  • As you prepare the resuscitation bay, you consider the differential of this patient’s presentation and how best to prepare for her arrival…
CASE 3
A distressed mother has brought her 4-year-old daughter to the ED because the girl has blood in her underwear…
  • The girl is sitting calmly on her mother’s lap, and mother says that the girl was “completely fine” yesterday.
  • The girl’s vital signs are within normal limits.
  • You wonder what could be causing the bleeding and how best to examine this child without traumatizing her…

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