246 Obstetrics and Gynecology Board Review •••
❍ What is the best medical treatment of severe acute menorrhagia related to anovulation?
High-dose estrogens. IV conjugated equine estrogen (CEE) for up to 24 hours (25 mg IV/IM every 4 hours),
followed with oral CEE (eg, 2.5 mg four times a day) for 21 to 25 days, with medroxyprogesterone acetate (10 mg
per day) for the last 10 days to induce bleeding. A Foley catheter can be placed to tamponade bleeding temporarily.
Antiemetics are required in 40% of patients.
❍ What are the risks of treatment with high dose estrogens?
DVT and PE, particularly with IV estrogen. Nausea/vomiting, particularly with oral estrogen therapy.
❍ Can severe acute menorrhagia related to anovulation be treated with progestins only?
Yes, but it is less effective. Treatment involves medroxyprogesterone acetate (20–40 mg per day in divided doses),
or megestrol acetate (40–120 mg per day), or norethindrone (5–10 mg per day) for 5–10 days. A 2 to 3 weeks
regimen may be prescribed to allow for an increase in the hemoglobin concentration of anemic patients.
❍ What is the best medical treatment of severe acute menorrhagia secondary to atrophic bleeding?
Ethinyl estradiol (10–20 mg) for 2 to 3 weeks.
❍ A patient is taking a low-dose OCPs. She experiences repetitive spotting during the first week of therapy.
How would you treat this?
Estrogen therapy for 7 days in addition to her OCP. This could be as conjugated estrogens 1.25 mg or estradiol
2.0 mg. This is preferable to changing pills. May reassure patient that this is normal and wait for 3 cycles, as most
of such symptoms resolve by that time, if not then may change the pill.
❍ What is the best pharmacologic approach to treat a woman with ovulatory cycles but heavy menses?
A prostaglandin synthetase inhibitor (such as naproxen), beginning with the onset of symptoms.
❍ What percentage decrease in blood loss can be expected with the use of a prostaglandin synthetase inhibitor?
Approximately 40% to 50%.
❍ What are the options for treatment of chronic or less severe acute menorrhagia?
OCPs, IUDs, NSAIDs, antifibrinolytics: tranexamic acid, danazol, D&C, and hysteroscopic endometrial ablation
(if completed child bearing).
❍ In what clinical situation is DUB best treated with a progestin containing IUD?
Bleeding associated with chronic illnesses (such as renal failure).
❍ In what clinical situations is DUB best treated with a GnRH agonist?
Renal failure, blood dyscrasia, or organ transplantation (especially liver transplantation).
❍ True or False: A woman with acute DUB having failed medical options and does not want a hysterectomy
may benefit from interventional radiology uterine artery embolization (UAE) procedures.
True, but only recommended if completed child bearing.