A menstruating woman complains of greater than
usual bleeding, which is either off her usual
schedule (metrorrhagia), lasts longer than a
typical period, or is heavier than usual
(menorrhagia) perhaps with crampy pains and
passage of clots.
What to do:
Obtain orthostatic pulse and blood pressure
measurements, a hematocrit, and pregnancy test
(urine or serum beta hCG). Try to quantify the
amount of bleeding by number of saturated pads used.
If there is significant bleeding, demonstrated by
tachycardia, lightheadedness, orthostatic pressure
changes, a pulse increase of more than 20 per
minute on standing, or a hematocrit below 30%,
start an intravenous line of lactated Ringer's
solution, and have blood ready to transfuse on
Obtain a menstrual, sexual, and reproductive
history. Are her periods usually irregular,
occasionally this heavy? Does she take oral
contraceptive pills, and has she missed enough to
produce estrogen withdrawal bleeding? Is an IUD in
place and contributing to cramps, bleeding, and
infection? Was her last period missed or light, or
this period late, suggesting an anovulatory cycle
or an ectopic? Might she be pregnant?
Perform a speculum and manual vaginal
examination, looking particularly for signs of
pregnancy, such as a soft, blue cervix, enlarged
uterus, or passage of fetal parts with the blood.
Ascertain that the blood is coming from the
cervical os, and not frorn a laceration, polyp, or
other vaginal or uterine pathology or infection.
Feel for adnexal masses, as well as pelvic fluid
If there is an intrauterine pregnancy,
determine whether this bleeding represents an
incomplete, inevitable, or threatened abortion.
Spread any questionable products of conception on
gauze or suspend in saline to differentiate from
organized clot. Press an 8mm curette or dilator
against the cervix to see whether the internal os
is open (indicating an inevitable or incomplete
abortion) or closed (threatened abortion, with
roughly even odds of survival, and generally
treated by bedrest).
Confirm suspicion of ectopic pregnancy either
with a sonogram showing the ectopic gestational
sac, a sonogram showing an empty uterus despite a
positive pregnancy test, or a culdocentesis, which
cannot rule out an ectopic pregnancy, but which
can quickly demonstrate blood in the cul-de-sac
after an ectopic sac ruptures.
Discharge the stable patient home on oral
contraceptive pills (Ortho-Novum 1/50 or Norinyl 1+50) one qid until the bleeding stops, then finishing the 28-day package one qid, followed by low-dose oral contraceptives for the next two to three months.
If the cause of the uterine bleeding was missed
oral contraceptive pills, the patient may resume
the pills, but should use additional contraception
for the first cycle. (If the cause is a new IUD,
the patient may elect to have it removed and use
The patient should be referred for followup to a
gynecologist, and may be evaluated via
What not to do:
Do not leap to a diagnosis of dysfunctional uterine bleeding without ruling
Do not rule out pregnancy or venereal infection
on the basis of a negative sexual history--confirm
with physical examination and laboratory tests.
The essential steps in the emergency evaluation of vaginal bleeding are fluid resuscitation of shock, if present, and recognition of pregnancy and its
complications of spontaneous abortion or ectopic pregnancy. Treatment of more chronic and less severe dysfunctional uterine bleeding usually consists of iron replacement and optional use of oral contraceptives to decrease menstrual irregularity (metrorrhagia) and volume (menorrhagia). Bed rest has not been shown to improve the outcome for a threatened abortion, but is still usually part of the regimen. Medroxyprogesterone (Provera) 10mg po x10d can also be given to stop dysfunctional uterine bleeding, but warn the patient to expect a heavy bleed when it is stopped.
Falcone T, Desjardins C, Bourque J, et al: Dysfunctional uterine bleeding in adolescents. J Reprod Med 1994;39:761-764.