GuidelinesOther guideline
Management Options for Heavy Bleeding
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Management options depend on the presumed diagnosis, and on the patient’s wishes regarding pregnancy
Medication
Drug treatment may be given for at least 3 months, and the patient may be reviewed after that, to continue or to stop treatment.
- Tranexamic acid (Cyclokapron) 0.5 to 1 g orally 3 times daily for the first 3 days of bleeding. Can reduce regular heavy bleeding by 50%. Useful for acute bleeding and long term. Does not make irregular bleeding regular. Do not prescribe in patients with a history of thromboembolism.
- Injectable Medroxyprogesterone acetate (Depo-Provera) 150 mg IM every 3 months, Norethisterone ethanoate(Nur-isterate) 200mg; useful for acute bleeding and long-term. At first, bleeding may be irregular, if this happens add 4 weeks of Norethisterone (Primolut) 10 mg orally twice daily. Reduce bleeding by 95-100%. Progestogens may cause slight weight gain, feeling of heaviness, oily skin, mood changes and rarely headache
- Medroxyprogesterone acetate (Provera) 5 mg orally twice daily for 21-28 days per month (never only 5-14 days: has no effect)
- Norethisterone (Primolut) 10 mg orally twice daily or 5 mg orally 3 times daily for 21-28 days per month (not 5-14 days, as the package insert suggests – this is ineffective); useful when bleeding is irregular
- Combined oral contraceptives. They also reduce dysmenorrhea and provide contraception. Beware of contraindications. Decrease bleeding up to 50%.
- Nonsteroidal anti-inflammatory drugs such as Ibuprofen 400 mg orally 3 times daily, mefenamic acid 500 mg orally 3 times daily, or naproxen 500 mg orally 3 times daily for the duration of bleeding. Useful for dysmenorrhea, but decrease bleeding variably 10-45%. Beware of contraindications – peptic ulceration, asthma, renal dysfunction.
- Levonorgestrel-containing intrauterine system (Mirena) is effective, not available at some public hospitals, irregular spotting may occur at first. Reduce bleeding 95-100%.
- For prolonged bleeding following use of Depo Provera, or oral contraceptives, one can give conjugated oestrogen (Premarin) 0.625 mg daily for three weeks, after demonstrating a thin endometrium on ultrasound.