Acute severe heavy uterine bleeding

Acute severe heavy uterine bleeding is an episode in a patient of reproductive age who is not pregnant, in which the quantity of bleeding requires immediate intervention to prevent further blood loss.

Occasionally, acute heavy menstrual bleeding may cause severe anaemia and clinical features of reduced circulatory volume. Pregnancy-related haemorrhage must be excluded.

Severe menstrual bleeding in adolescents, especially if it occurs from menarche, should be investigated for coagulation disorders. If the adolescent is otherwise healthy, severe menstrual bleeding usually reflects an immature hypothalamic–pituitary–ovarian axis causing anovulatory cycles.

Severe menstrual bleeding in adults with established menstrual cycles require investigation for an underlying cause (once haemodynamically stable), particularly for new-onset heavy bleeding or if risk factors for malignancy are present. See also Indications for specialist referral.

Evidence for how best to stop acute severe heavy uterine bleeding is lacking. Use the lowest effective drug dose, especially in adolescents, but high doses may be necessary in the short term to control bleeding.

Hormonal treatments include:

Tapering the dose over a few weeks is suggested. This may reduce the volume of withdrawal bleeding when progestogen is stopped, although evidence is lacking. Advise that a withdrawal bleed is likely to occur once therapy is stopped.

Occasionally if cyclical oral progestogens do not control heavy menstrual bleeding, high-dose estrogen may be required (given as a combined oral contraceptive [COC]), but this is usually poorly tolerated due to nausea. Use:

Tapering the dose of the COC is also suggested over a few weeks although evidence is similarly lacking. Advise that a withdrawal bleed is likely to occur once the COC is stopped.

Caution is advised with high doses of estrogen and progestogen in individuals at risk of venous thromboembolism.

An antiemetic is recommended with hormonal therapy used for acute severe heavy uterine bleeding.

An alternative to hormonal therapy in acute heavy severe uterine bleeding is tranexamic acid. Caution is advised in individuals with an increased risk of thromboembolism.

In a general practice setting, use oral therapy. In a hospital setting, oral or intravenous therapy can be used; choice depends on clinical assessment of the patient, clinical preference and availability of formulations.

For oral therapy, use:

For intravenous therapy (in a hospital setting), use:

Tapering of tranexamic acid is not required. To prevent heavy menstrual bleeding from recurring in subsequent months, see Approach to treatment of heavy menstrual bleeding.