Stable Patients

If the patient is stable and not significantly anaemic, she may be treated as an outpatient with one or more of the medical treatments described below.4 The aim of treatment is to reduce both the duration and volume of blood loss, to treat anaemia if present, and to restore quality of life.4,23 Medical treatment of stable, non-pregnant patients with vaginal bleeding can be divided into non-hormonal and hormonal treatments.13 When discussing and agreeing a treatment option with the patient, take into account her preferences, comorbidities, cause for the bleeding and other symptoms she is experiencing e.g. pain/pressure.8

NICE guidelines permit the initiation of pharmacological treatment for HMB without investigating the cause if the history and/or examination suggests a low risk for structural or histological abnormality e.g. persistent IMB, PCB, pressure symptoms, pain, uterus size or pelvic mass.8,28

Pharmacological treatment options are as follows:

  • Non-Hormonal Treatments
    • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) e.g. ibuprofen, mefenamic acid, naproxen
      • Promote uterine vasoconstriction, thus reducing HMB.13,21
      • Different NSAIDs appear to be equally effective at reducing HMB.13,29
      • Contraindications include hypersensitivity to aspirin or an NSAID, peptic ulcer disease, use of anticoagulants, renal and cardiac impairment etc.
      • Also have analgesic properties which can be useful for dysmenorrhoea.
      • They are as effective as oral contraceptives at reducing HMB but less effective than tranexamic acid and the levonorgestrel-releasing intrauterine system (LIUS) e.g. Mirena coil.29
    • Tranexamic acid
      • Antifibrinolytic which is more effective for the treatment of HMB than NSAIDs and oral contraceptives but less so than the LIUS.21,30
      • Does not appear to be associated with an increase in major adverse events but there is insufficient evidence to assess thromboembolism risk.30
      • May be given in conjunction with NSAIDs.9
    • Iron supplementation
      • Should be started in patients with microcytic anaemia.4
      • Vitamin C given in conjunction with iron may improve absorption.4
  • Hormonal Treatments
    • Combined Oral Contraceptive Pill (COCP)
      • Can be prescribed as a taper to temporize an episode of heavy bleeding.4,13
      • Most effective for patients with bleeding secondary to anovulation.13
      • Contraindications to the COCP include:4,13
        • Pregnancy
        • Liver disease
        • Severe uncontrolled hypertension
        • History of stroke or thromboembolic event
        • Age>35 in those who smoke
        • History of breast/liver cancer (particularly oestrogen dependent tumours)
        • Cerebrovascular or ischaemic heart disease
        • Hypertriglyceridemia
    • Progesterone Only Pill (POP)
      • May be a safe alternative if the COCP is contraindicated.4,13
    • Levonorgestrel-releasing intrauterine system (LIUS) e.g. Mirena coil
      • Very effective at reducing HMB21 but not typically an option in ED.
      • Can cause an initial change in bleeding pattern, often causing erratic bleeding, particularly in the first few cycles.8,9