<< Emergency Department Management Of Vaginal Bleeding In The Nonpregnant Patient


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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Abnormal uterine bleeding drives most visits gynecologists [press release]. Washington (DC): American College of Obstetricians and Gynecologists; July 21, 2012. (News release)
  2. * Committee on Practice Bulletins--Gynecology. Practice Bulletin No. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gyncecol. 2012;120(1):197- 206. (Practice guidelines)
  3. No authors listed. ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206-218. (Practice guideline)
  4. * American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 557: management of acute abnormal uterine bleeding in nonpregnant reproductiveaged women. Obstet Gynecol. 2013;121(4):891-896. (Practice guidelines)
  5. Lobo RA. Abnormal uterine bleeding: ovulatory and anovulatory dysfunctional uterine bleeding: management of acute and chronic excessive bleeding. In: Lentz GM, Lobo RA, Gershenson DM, et al, eds. Comprehensive Gynecology. Philadelphia: Mosby-Elsevier; 2012:805-814. (Textbook chapter)
  6. Tibbles CD. Selected gynecologic disorders: abnormal uterine bleeding in the nonpregnant patient. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby-Elsevier; 2010: 1325-1332. (Textbook chapter)
  7. Oehler MK, Rees MCP. Menorrhagia: an update. Acta Obstet Gynecol Scand. 2003;82(5):405-422. (Review)
  8. Munro MG. Classification of menstrual bleeding disorders. Rev Endocr Metab Disord. 2012;13(4):225-234. (Review)
  9. Fraser IS, Critchley HOD, Munro MG, et al. Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod. 2007;22(3):635-643. (Review)
  10. Beazley JM. Dysfunctional uterine hemorrhage. British Journal of Hospital Medicine. 1972;7:573-587. (Review)
  11. Sheppard BL. The pathology of dysfunctional uterine bleeding. Clin Obstet Gynaecol. 1984;11(1):227-236. (Review)
  12. ACOG Committee on Adolescent Health Care. ACOG Committee Opinion No. 349, November 2006: menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2006;108(5):1323-1328. (Practice guideline)
  13. World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls. II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health Care. 1986;7(4):236-244. (Longitudinal study; 1472 patients)
  14. Flug D, Largo RH, Prader A. Menstrual patterns in adolescent Swiss girls: a longitudinal study. Ann Hum Biol. 1984;11(6):495-508. (Longitudinal study; 140 patients)
  15. Beckmann KR, Melzer-Lange MD, Gorelick MH. Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey. Ann Emerg Med. 2004;43(3):333- 338. (Retrospective cross-sectional study; 18,999 patient records)
  16. Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol. 1981;139(3):277-280. (Case review; 59 patients)
  17. Bevan JA, Maloney KW, Hillery CA, et al. Bleeding disorders: a common cause of menorrhagia in adolescents. J Pediatr. 2001;138(6):856-861. (Retrospective chart review; 71 patients)
  18. Stamatellos I. The role of hysteroscopy in the current management of the cervical polyps. Arch Gynecol Obstet. 2007;276(4):299-303. (Review)
  19. Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1):100- 107. (Comparative study; 1364 patients)
  20. Munro MG. Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management. Obstet Gynecol Clin North Am. 2011;38(4):703-731. (Review)
  21. Magnotti M, Futterweit W. Obesity and polycystic ovarian syndrome. Med Clin North Am. 2007;91(6):1151-1168. (Review)
  22. * Daniels RV, McCuskey C. Abnormal vaginal bleeding in the nonpregnant patient. Emerg Med Clin N Am. 2003;21(3):751- 772. (Evidence-based review)
  23. Pretorius R, Semrad N, Watring W. Presentation of cervical cancer. Gynecol Oncol. 1991;42(1):48-53. (Prospective study; 81 patients)
  24. Reinhold C, Khalili I. Postmenopausal bleeding: value of imaging. Radiol Clin N Am. 2002;40(3):527-562. (Evidence-based review)
  25. Brenner PF. Differential diagnosis of abnormal uterine bleeding. Am J Obstet Gynecol. 1996;175(3 Pt 2)766-769. (Review)
  26. Karlsson B, Granberg S, Hellberg P, et al. Comparative study of transvaginal sonography and hysteroscopy for the detection of pathologic endometrial lesions in women with postmenopausal bleeding. J Ultrasound Med. 1994;13(10):757- 762. (Comparative study; 51 patients)
  27. Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol. 2004;190(5):1216-1223. (Survey; 226 respondents)
  28. Chimbira TH, Anderson AB, Turnbull AC. Relation between measured menstrual blood loss and patient’s subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area. Br J Obstet Gynaecol. 1980;87(7):603-609. (Observational study; 92 patients)
  29. Gannon MJ, Day P, Hammadieh N, et al. A new method for measuring menstrual blood loss and its use in screening women before endometrial ablation. Br J Obstet Gynaecol. 1996;103(10):1029-1033. (Prospective observational study; 372 patients)
  30. Cameron IT. Dysfunctional uterine bleeding. Ballieres Clin Obstet Gynaecol. 1989;3(2):315-327. (Review)
  31. Grimes DA. Estimating vaginal blood loss. J Reprod Med. 1979;22(4):190-192. (Basic science)
  32. Fraser IS, McCarron G, Markham R. A preliminary study of factors influencing perception of menstrual blood loss volume. Am J Obstet Gynecol. 1984;149(7):788-793. (Doubleblind placebo-controlled crossover trial; 69 patients)
  33. Santer M, Wyke S, Warner P. What aspects of periods are most bothersome for women reporting heavy menstrual bleeding? Community survey and qualitative study. BMC Womens Health. 2007;7:8. (Survey; 906 respondents)
  34. O’Flynn N, Britten N. Menorrhagia in general practice—disease or illness. Soc Sci Med. 2000;50(5):651-661. (Qualitative interview; 21 patients)
  35. Morrell MJ, Hayes FJ, Sluss PM, et al. Hyperandrogenism, ovulatory dysfunction, and polycystic ovary syndrome and valproate versus lamotrigine. Ann Neurol. 2008;64(2):200-211. (Prospective randomized controlled trial; 447 patients)
  36. Madhusoodanan S, Parida S, Jimenez C. Hyperprolactinemia associated with psychotropics—a review. Hum Psychopharmacol. 2010;25(4):281-297. (Evidence-based review)
  37. Fox KE. Management of heavy menstrual bleeding in general practice. Curr Med Res Opin. 2012;28(9):1517-1525. (Evidence-based review)
  38. Marret H, Fauconnier A, Chabbert-Buffet N, et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol. 2010;152(2):133-137. (Review)
  39. Jones IS, O’Connor A. Non-obstetric vulva trauma. Emerg Med Australas. 2013;25(1):36-39. (Retrospective case series; 519 patients)
  40. Price DH, Tracy CS, Upshur REG. Chaperone use during intimate examinations in primary survey of family physicians. BMC Fam Pract. 2005;6:52. (Survey; 257 respondents)
  41. Chi C, Pollard D, Tuddenham EGD, et al. Menorrhagia in adolescents with inherited bleeding disorder. J Pediatr Adolesc Gynecol. 2010;23(4):215-222. (Retrospective review; 153 patients)
  42. de Vries CJ, Wieringa-de Waard M, Vervoort CL, et al. Abnormal vaginal bleeding in women of reproductive age: a descriptive study of initial management in general practice. BMC Women’s Health. 2008;8:7. (Descriptive study; 270 patients)
  43. Davidson KG, Dubinsky TJ. Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding. Radiol Clin N Am. 2003;41(4):769-780. (Review)
  44. 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(3):285-291. (Prospective randomized controlled trial; 34 patients)
  45. * Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin N Am. 2008;35(2):219-234. (Review)
  46. Francois KE, Foley MR. Antepartum and Postpartum Hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Normal and Problem Pregnancies. Philadelphia, PA: Elsevier; 2012: 415-444. (Textbook chapter)
  47. Gutierrez G, Brotherton J. Management of severe anemia secondary to menorrhagia in a Jehovah’s Witness: a case report and treatment algorithm. Am J Obstet Gynecol. 2011;205(2):e5-e8. (Case report)
  48. Hossain N, Shamsi Ts, Feroz A. Successful management of acute catastrophic juvenile vaginal bleeding in Glanzmann’s thromboasthenia by uterine tamponade: A case report and review of the literature. Case Rep Hemtaol. 2012;2012:530908. (Case report)
  49. Schlicher NR. Balloon compression as treatment for refractory vaginal hemorrhage. Ann Emerg Med. 2008;52(2):148- 150. (Case report)
  50. McCluggage WG. My approach to the interpretation of endometrial biopsies and curettings. J Clin Pathol. 2006; 59(8):801-812. (Review)
  51. * Farquhar C, Brown J. Oral contraceptive pill for heavy menstrual bleeding. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD000154. (Evidence-based review)
  52. Fraser IS, McCarron G. Randomized trial of 2 hormonal and 2 prostaglandin-inhibiting agents in women with a complaint of menorrhagia. Aust N Z J Obstet Gynaecol. 1991;31(1):66-70. (Randomized crossover trial; 45 patients)
  53. Davis A, Godwin A, Lippman J, et al. Triphasic norgestimate- ethinyl estradiol for treating dysfunctional uterine bleeding. Obstet Gynecol. 2000;96(6):913-920. (Randomized controlled trial; 201 patients)
  54. Munro MG, Mainor N, Basu R, et al. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006;108(4):924-929. (Randomized controlled trial; 40 patients)
  55. Sweet MG, Schmidt-Dalton TA, Weiss PM, et al. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012;85(1):35-43. (Review)
  56. Jensen JT, Mishell DR. Family planning: contraception, sterilization, and pregnancy termination. In: Lentz, GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. Philadelphia, PA: Mosby-Elsevier; 2012:215-272. (Textbook chapter)
  57. Zacur HA. Managing an episode of severe or prolonged uterine bleeding. In: Basow, DS, ed. UpToDate®. Waltham, MA: UpToDate®; 2013. (Online textbook chapter)
  58. van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ. 2009;339:b2921. (Casecontrol study; 1524 patients, 1760 controls)
  59. Aksu F, Madazli R, Budak E, et al. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust N Z J Obstet Gynaecol. 1997;37(2):228-231. (Clinical trial; 24 patients)
  60. Grossheim LF, Metz R. Vaginal bleeding in nonpregnant patients. Critical Decisions in Emergency Medicine. 2013;27(2):13- 21 (Evidence-based review)
  61. Mantha S, Karp R, Raghavan V, et al. Assessing the risk of venous thromboembolic events in women taking progestinonly contraception: a meta-analysis. BMJ. 2012. 345:e4944. (Meta-analysis; 8 studies)
  62. * Cirilli AR, Cipot SJ. Emergency evaluation and management of vaginal bleeding in the nonpregnant patient. Emerg Med Clin North Am. 2012;30(4):991-1006. (Evidence-based review)
  63. Nelson AL, Teal SB. Medical therapies for chronic menorrhagia. Obstet Gynecol Surv. 2007;62(4):272-281. (Review)
  64. Roy SN, Bhattacharya S. Benefits and risks of pharmacological agents used for the treatment of menorrhagia. Drug Saf. 2004;27(2):75-90. (Evidence-based review)
  65. * Lethaby A, Duckitt K, Farquhar C. Non-steroidal antiinflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013 Jan 31;1:CD000400. (Evidence-based review)
  66. Hall P, Maclachlan N, Thorn N, et al. Control of menorrhagia by the cyclooxygenase inhibitors naproxen sodium and mefenamic acid. Br J Obstet Gynaecol. 1987;94(6):554-558. (Double-blind crossover study; 35 patients)
  67. Kadir RA, Lukes AS, Kouides PA, et al. Management of excessive menstrual bleeding in women with hemostatic disorders. Fertil Steril. 2005;84(5):1352-1359. (Review)
  68. Lumsden MA, Wedisinghe L. Tranexamic acid therapy for heavy menstrual bleeding. Expert Opin Pharmacother. 2011;12(13):2089-2095. (Evidence-based review)
  69. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249. (Evidence-based review)
  70. Leminen H, Hurskainen R. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health. 2012;4:413-421. (Evidence-based review)
  71. Barbieri RL. Long offered abroad by Rx, OTC: A new (to the US) first-line agent for heavy menstrual bleeding. OBG Management. 2010;22(10):9-12. (Evidence-based review)
  72. Alleyne M, Horne MK, Miller JL. Individualized treatment for iron-deficiency anemia in adults. Am J Med, 2008;121(11):943-948. (Review)
  73. Carson JL, Grossman BJ, Clinical Transfusion Medicine Committee of the AABB, et al. Red blood cell transfusion: a clinical practice guideline for the AABB. Ann Intern Med. 2012;157(1):49-58. (Systematic review; 19 studies)
  74. Carson JL, Carless PA, Herbert PC. Transfusion thresholds and other strategies for guiding allogenic red blood cell transfusion. Cochrane Database Syst Rev. 2012 Apr 18;4:CD002042. (Systematic review; 19 studies)
  75. Pinkerton JV. Pharmacological therapy for abnormal uterine bleeding. Menopause. 2011;18(4):453-461. (Review)
  76. Beaumont H, Augood C, Duckitt K, et al. Danazol for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001017. (Systematic review)
  77. McWilliams GDE, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin N Am. 2008;88(2):265-283. (Review)
  78. Fothergill RE. Endometrial ablation in the office setting. Obstet Gynecol Clin N Am. 2008;35(2):317-330. (Review)
  79. Munro MG. Complications of hysteroscopic and uterine resectoscopic surgery. Obstet Gynecol Clin North Am. 2010;37(3):399-425. (Review)
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  82. Striegel AM, Myers JB, Sorensen MD, et al. Vaginal discharge and bleeding in girls younger than 6 years. J Urol. 2006:176(Pt 1):2632-2635. (Retrospective chart review; 24 patients)
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  97. Adams JA, Knudson S. Genital findings in adolescent girls referred for suspected sexual abuse. Arch Pediatr Adolesc Med. 1996;150(8):850-857. (Patient series, medical chart, and photograph review; 204 patients)
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  110. Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013. 208(6):499.e1-e5. (Prospective single-arm pilot clinical trial; 48 patients)
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Joelle Borhart, MD

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August 2, 2013

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