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