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What to D.O.

Once Stuck in a Therapeutic Fog, Abnormal Uterine Bleeding Finds Clarity

Pescatore, Richard DO

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doi: 10.1097/01.EEM.0000531127.24003.53

    NEW COLUMN

    uterine bleeding
    uterine bleeding:
    uterine bleeding
    Figure
    Figure

    Like most EPs, there is a catalogue of chief complaints that I hate seeing pop up in the waiting room—vague paresthesias that seem to worsen in the middle of the night, nonsensical grumblings of longstanding malaise. We all know the list: Questionably emergent (or even urgent) ailments that rarely result in a good experience for the patient or the provider.

    For a long time, the nonpregnant patient presenting with vaginal bleeding has belonged firmly in that frustrating category. It's a story all too common to our fluorescent-lit halls; a similarly exasperated woman with days and days of bleeding needs “something to be done.” Her OB/GYN has no appointments available for the next seven years or so, and trials of home remedies nearly always culminate in a 2 a.m. ED visit.

    We're often at a loss—it's rare that these patients ever need even the simplest of emergency interventions. CBCs and INRs may be drawn as a courtesy or compromise, but they usually serve only to delay the inevitably disappointing discussion. They're not going to be admitted for an emergent hysterectomy, and their gynecologist isn't coming to the bedside in the middle of the night. We send them home with admonitions to follow up, in the hopes that a panicked post-ED call might help find a hole in their doctor's schedule. Often we struggle with therapeutic options, concerned that well-intentioned interventions might result in life-threatening blood clots or other unexpected complications.

    There's a better way. Beginning in 2011, the world of OB/GYN began to simplify this wearisome and tedious cycle, starting with a clarification of the very entity with which we're dealing. Confusing terms like menorrhagia, metrorrhagia, and dysfunctional uterine bleeding have all been supplanted by the FIGO classification. (Int J Gynaecol Obstet 2011;113[1]:3.)

    The diagnosis for all of these patients is now much more straightforward: abnormal uterine bleeding (AUB). The FIGO system allows for subclassification of AUB, but such specificity is simply not needed in the ED. Previous confusion about irregularity versus heaviness or concern for structural or hormonal abnormalities all falls under the AUB umbrella.

    Beyond NSAIDs

    Not only have the terminology and diagnosis been clarified, so has our therapeutic approach. Most clinicians are well aware of the long-recommended first-line therapy for AUB. NSAIDs provide about a 50 percent reduction in bleeding volume with a wide margin of safety and limited downside. (J Gynecol Obstet Hum Reprod 2017;46[8]:613.) Our patients have usually attempted NSAID therapy without success, and this simple intervention is met with a scoff. From what I've seen, many ED providers seem loath to progress to second-line therapy. Indeed, during residency, it was considered heresy to suggest more advanced therapies, lest the patient immediately develop a pulmonary embolism outside of her lawyer's office. Discussions on the EMDocs Facebook page and among my colleagues echo those fears.

    Fortunately, the 2013 ACOG Committee Opinion on management of AUB provides guidance and medico-legal support for initiation of more effective therapies from the ED. (Obstet Gynecol 2013;121[4]:891.) The guideline lists several options of various efficacy, but high-dose progestin (medroxyprogesterone acetate, 20 mg tid x 7 days) is perhaps the best compromise between efficacy and safety. It stops bleeding in as much as 76 percent of patients (Obstet Gynecol 2006;108[4]:924) with no evidence of increased venous thromboembolic risk across eight observational studies. (BMJ 2012;345:e4944.) Obviously, caution should be taken and patients counseled, but this literature provides a strong evidence base and justification for emergency physician comfort with progesterone treatment of AUB.

    An additional option exists for those uncomfortable with initiating hormonal therapy, and comes in a form more familiar to the practicing emergency physician: tranexamic acid. TXA continues to seep into our management paradigms, with excellent utility in bleeding complaints ranging from massive hemorrhage to piddling epistaxis.

    Lysteda, its oral form, was approved in 2009 by the Food and Drug Administration, and multiple randomized trials have demonstrated efficacy at least comparable with oral progestins (Cochrane Database Syst Rev 2000;[4]:CD000249), and large safety reviews have consistently demonstrated no increased rates of VTE or other limiting adverse events. (Int J Womens Health 2012;4:413.) For the patient in whom progestin therapy may be undesired or ineffective, TXA (1.3 g tid x 3-5 days) is another safe and effective treatment.

    The literature and guidelines produced by our OB/GYN colleagues have provided an excellent resource for emergency clinicians facing bedside battles in managing abnormal uterine bleeding. These have removed AUB from its place among the most dissatisfying patient encounters, and allow emergency physicians to provide rewarding and effective care with confidence.

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