Acute Uterine Bleeding Unrelated to Pregnancy: A Southern California Permanente Medical Group Practice Guideline

Abstract

Acute uterine bleeding unrelated to pregnancy has been defined as bleeding "sufficient in volume as to, in the opinion of the treating clinician, require urgent or emergent intervention." The Southern California Permanente Medical Group updated its guidelines for the management of this condition on the basis of the best available evidence, as identified in a systematic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on opinion or other sources such as case series that are, in general, categorized as low-quality evidence. Medical interventions with single or combined gonadal steroidal agents administered parenterally or orally show promise, but more high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling. There is also some evidence that intrauterine tamponade may be useful in at least selected cases. Special attention must be paid to both diagnosing and treating inherited disorders of hemostasis, such as von Willebrand disease, that may otherwise be underdiagnosed in both adolescent and adult women.

Vaginal Bleeding in the Nonpregnant Patient Received in Emergency at Yalgado Ouedraogo University Hospital of Ouagadougou, Burkina Faso

“…The clinical condition of women most often results in frequent use of emergency care. According to Malcom G, knowledge about pathogenesis and guidelines for the management of this clinical problem was lacking, with relatively little basic or clinical research in the field [4]. Metrorrhagia is a real public health problem.…”

Abnormal uterine bleeding guidelines and clinical practice are based on poor quality evidence

“…She was also transfused with a total of 8 units of pRBCs. Although not supported by RCT evidence, 3 after twenty-four hours she was switched to a course of oral Megace® as is generally done following Premarin ® treatment until a hysterectomy could be performed. Hemoglobin stabilized at 11.0 g/dL after four days.…”

“…but no RCTs have examined combination OCs specifically. 3,4 Currently, both medroxyprogesterone acetate and combination OC regimens have never individually been shown to significantly improve AUB outcomes over no treatment. Our ability to draw conclusions about the efficacies of these treatments is extremely limited because we are unable to determine with certainty if cessation of AUB was achieved by the administration of these hormonal therapies or because it would have stopped regardless.…”

“…4,5 Tranexamic acid, an antifibrinolytic, has not yet specifically been analyzed in a RCT for acute AUB. 3,6 In order to ensure best practice in the case of A.F., medroxyprogesterone acetate and combination OCs as studied in a RCT by Munro et al and cited in ACOG recommendations was evaluated as an alternative treatment to Premarin® and forms the basis of this critical appraisal. Munro et al compared the efficacy of medroxyprogesterone acetate (20 mg TID for 7 days then daily for 3 weeks) with a combination OC (1 mg norethindrone and 35 μg ethinyl E2 TID for 7 days then daily for 3 weeks) as a therapy for acute AUB in 40 patients.…”

“…Research Article Munro MG 2,3 According to these recommendations, accepted medical therapies include IV conjugated equine estrogen (CEE), combination oral contraceptives (OC), medroxyprogesterone acetate, or tranexamic acid. Each of these recommended therapies is based on a single RCT.…”