Abnormal uterine bleeding is the most common reason women seek gynecologic care, and many of these women present to an emergency department for evaluation. It is essential that emergency clinicians have a thorough understanding of the underlying physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to guide the management of nonpregnant patients with abnormal bleeding is limited, and recommendations are based mostly on expert opinion. This issue reviews common causes of abnormal bleeding, including anovulatory, ovulatory, and structural causes in both stable and unstable patients. The approach to abnormal bleeding in the prepubertal girl is also discussed. Emergency clinicians are encouraged to initiate treatment to temporize an acute bleeding episode until timely follow-up with a gynecologist can be obtained.
Key words: abnormal uterine bleeding, nonpregnant vaginal bleeding, heavy menstrual bleeding, prepubertal bleeding
It’s the middle of a busy night shift in the ED, and a 23-year-old woman with vaginal bleeding has been waiting several hours to be seen. Her vital signs are normal. She has no past medical history and takes no medications. She states that she has been bleeding continuously for the past 2 weeks. Her menstrual periods have always been irregular, but she has never bled for this long. She describes the bleeding as heavy, sometimes with clots, and she is frequently changing her sanitary pad. A pregnancy test was ordered from triage and is negative. The patient is desperate for you to stop the bleeding, and you wonder if there is anything you can offer her besides a box of tampons and a gynecology referral….
As you walk out the room, the radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours….
Abnormal uterine bleeding is the most common reason women seek gynecologic care,1 and many of these women present to an emergency department (ED) for evaluation. Abnormal vaginal bleeding can be very distressing for a woman. At a minimum, it is an inconvenience that disrupts her daily life; in severe cases, bleeding can result in life-threatening hemorrhage requiring emergency intervention. Abnormal bleeding may also herald a serious underlying pathology such as cancer. Many women presenting to the ED for evaluation of vaginal bleeding fear that they are in the serious category, and the provider must be sensitive to her concerns. The role of the emergency clinician is to rule out life-threatening complications associated with abnormal uterine bleeding and to obtain emergent, urgent, or routine gynecologic consultation as needed. Emergency clinicians are often hesitant to initiate therapies to temporize a stable patient’s bleeding, instead deferring this to a gynecologist on an outpatient basis. The goal of this issue of Emergency Medicine Practice is to provide an evidence-based approach to the nonpregnant woman presenting with vaginal bleeding.
A literature search was performed using PubMed, including the search terms menorrhagia, abnormal uterine bleeding, nonpregnant vaginal bleeding, dysfunctional uterine bleeding, and heavy menstrual bleeding.
The resulting 6000 abstracts were reviewed for applicability, and results were limited to the English language and to articles published in the last 20 years. Emphasis was placed on trials conducted in the ED or in the acute clinical setting. Additional references were identified by reviewing bibliographies of relevant articles. The Cochrane Database of Systematic Reviews was searched using the term heavy menstrual bleeding, yielding 41 results, 14 of which were applicable to this review. The National Guideline Clearinghouse (www.guideline.gov) was queried using the search term heavy menstrual bleeding. A total of 24 guidelines were found, 2 of which were applicable to this review.2,3 Both of the guidelines were produced by the American College of Obstetricians and Gynecologists (ACOG). ACOG also recently released a Committee Opinion on the management of abnormal uterine bleeding, which is included in this review.4 There are currently no American College of Emergency Physicians (ACEP) clinical policies that apply to vaginal bleeding in the nonpregnant patient.
It is inherently difficult to form an evidencebased approach to guide the treatment of the nonpregnant patient with vaginal bleeding because high-quality evidence is currently lacking. Unfortunately, there are no large prospective randomized controlled trials, and we must rely on expert opinion, observational studies, and case reports for guidance. Of the few small randomized controlled trials that are available, there is great variability of outcomes across the studies, making comparisons of different interventions difficult.
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.
Joelle Borhart, MD
August 2, 2013