Hello, I am an ER resident and recently I have had a string of patients presenting with mild-mod heavy, non-preg UB. Many of these patients have never been on OCP's and have been very interested in starting OCPs to help with their heavy bleeding and on-going contraception. Our pharmacy carries many OCPs with variable progestin strength (example NECON .5/.3 and 1/.3). After trying to review the literature, I cannot find any guidelines on the dosing of OCPs and was wondering if yall had any resources or advice. Bonus question - when would you reach for progestin-therapy specifically for AUB and any other tips for heavy AUB that is not quite serious enough to warrant more aggressive treatment (IV EE, TXT, high-dose progestin).
Thanks!
There are several dosing regimens for acute vaginal bleeding management using combined oral contraceptives. You should use a monophasic pill and need at least 30 to 35 mcg of ethinyl estradiol in them.
If a patient is in the ER and I am consulted for abnormal bleeding and the US and exam are benign. I typically send them out on a high dose progesterone regimen (one of the ones below) with instructions to follow up with me as an outpatient or their Family physician/OBGYN.
Regimen 1:
Provera 10mg tablets
Two tabs PO BID for 7 days followed by two tabs daily for 21 days
This comes out to 84 tablets total. Sometimes the pharmacist will call me to make sure I mean this dosing. I kindly refer them to the appropriate peer reviewed journal article if I have the time and tell them I know what I am doing.
This is a published regimen and has a high degree of success and will stop the vast majority of bleeding with minimal side effects. The purpose is to stop the bleeding so patients can get the appropriate work up (biopsy etc). It can be too successful so the patient ends up blowing off their follow up since they are no longer bleeding while taking this regimen.
Regimen 2:
Depo Provera 150mg x 1
Send them home with provera 10mg.
Two tabs PO BID for 3 days
Either regimen works with minimal side effects (little to no nausea). The depo provera will provide contraception but the provera regimen technically won't protect against pregnancy.
My patient population is generally obese/hypertensive/poor health and I generally don't like slamming them with a ton of estrogen .
You can use a combined OCP regimen to stop acute bleeding but again it depends on the etiology. Patients will get nauseous thought. You will need to use a monophasic pill with at least 30-35mcg of ethinyl estradiol.
One regimen is as follows:
5 pills on day one. 4 pills on day two. 3 pills on day three. 2 pills on day two. 1 pill daily until bleeding subsides and then allow a withdrawal bleed.
Similarly, you can take 1 pill TID for 7 days (35mcg EE/1mg norethindrone) and then switch to a low dose pill once daily(20mcg EE/1mg norethindrone).
Regarding when to use estrogen or TXA.
If a patient is hemodynamically unstable, IV estrogen does work quickly but will have increased risk.
You can always given patient a Rx for Lysteda (TXA for menstrual bleeding)1.3mg TID for 5 days for outpatient use.
As far as starting OCPs for the purpose of contraception. Knock yourself out but if a patient is bleeding enough to warrant a visit to the ED, they need to follow up with a gynecologist for an appropriate work up.
US for structural lesions
Blood work (von Willebrands, if they are skipping menses for months and then having a huge bleed due to PCOS etc)
Pelvic exam etc
The ED is not their primary care and in my experience at least half of patients will have some issue with the first birth control prescribed and will need to adjust so they need some type of legitimate follow up.
