• References [1,2]
Structural causes Nonstructural causes
Polyps (cervical, endometrial) Coagulopathy
(particularly Von Willebrand disease)
Adenomyosis
(endometrial glands within the uterine muscle)
Ovulatory dysfunction
Leiomyoma (fibroids) Endometrial
(hyperplasia, dysfunctional uterine bleeding)
Malignancy
(endometrial, cervical, vaginal)
Iatrogenic
(laceration, etc.)
Other
(thyroid disease, thrombocytopenia, leukemia, kidney failure, liver failure)


  • References [1]
Patients Tests
All
  • CBC
  • Blood type cross and match (if bleeding is severe)
  • Pregnancy test
Most patients
  • Pelvic ultrasound
  • Pelvic exam with PAP smear
Patients at risk for coagulopathy
(see coagulopathy screening below)
  • activated Partial Thromboplastin Time (aPTT)
  • Prothrombin time (PT-INR)
  • Testing for von Willebrand disease
  • Fibrinogen
Women ≥ 45 years old
  • Endometrial biopsy
Other considerations in appropriate patients
  • Thyroid testing
  • Iron studies
  • Liver function tests
  • Chlamydia testing


  • References [1]
ACOG recommendations for coagulopathy screening in menorrhagia
Screen patients for coagulopathy if they meet any 1 of the following 3 criteria:
1. Heavy menstrual bleeding since menarche
2. One of the following:
  • Postpartum hemorrhage
  • Surgery-related bleeding
  • Bleeding with dental work
3. Two or more of the following:
  • Bruising, 1 - 2 times per month
  • Nosebleed, 1 - 2 times per month
  • Frequent gum bleeding
  • Family history of bleeding problems


  • References [1]
Acute treatment for uncontrolled bleeding - ACOG recommendations
Conjugated estrogens injection (Premarin®)
  • Dosing: 25 mg IV every 4 - 6 hours for 24 hours
  • Other:
    • Shown to stop bleeding within 8 hours in 72% of patients
    • May cause significant nausea. Give with nausea medication.
    • See female hormone medications for more
Monophasic OCP with 35 mcg of ethinyl estradiol
  • Dosing: One tablet three times a day for 7 days
  • Other:
    • Shown to stop bleeding in 88% of patients
    • May cause significant nausea. Give with nausea medication.
    • See oral contraceptive chart for more
Medroxyprogesterone (Provera®)
  • Dosing: 20 mg three times a day for 7 days
  • Other:
    • Shown to stop bleeding in 76% of patients
    • May cause significant nausea. Give with nausea medication.
    • See female hormone medications for more
Tranexamic acid (Lysteda®)
  • Dosing:
    • Oral: 1.3 grams three times a day for 5 days
    • IV: 10 mg/kg (max 600 mg/dose) every 8 hours for 5 days
  • Other:
    • Tranexamic acid binds plasminogen and prevents it from dissolving fibrin
    • Contraindicated in women at increased risk for venous or arterial thromboembolism
    • See Lysteda® PI for dosing in kidney disease