Structural causes Nonstructural causes
Polyps (cervical, endometrial) Coagulopathy
(particularly Von Willebrand disease)
(endometrial glands within the uterine muscle)
Ovulatory dysfunction
Leiomyoma (fibroids) Endometrial
(hyperplasia, dysfunctional uterine bleeding)
(endometrial, cervical, vaginal)
(laceration, etc.)
(thyroid disease, thrombocytopenia, leukemia, kidney failure, liver failure)

Patients Tests
  • 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)
Women ≥ 45 years old
  • Endometrial biopsy
Other considerations in appropriate patients
  • Thyroid testing
  • Iron studies
  • Liver function tests
  • Chlamydia testing

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

ACOG recommendations for treating acute, uncontrolled uterine bleeding
Drug Dosage Other
Conjugated estrogens injection
25 mg IV every 4 - 6 hours for 24 hours
  • Shown to stop bleeding within 8 hours in 72% of patients
  • May cause significant nausea. Give with nausea medication.
  • See Estrogen contraindications
Monophasic OCP with
35 mcg of ethinyl estradiol
One tablet three times a day for 7 days
20 mg three times a day for 7 days
Tranexamic acid
  • 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
  • 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