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Author: Amir Estephan, MD; Chief Editor: Pamela L Dyne, MD
Updated: Oct 31, 2014

Abnormal uterine bleeding is a common presenting problem in the ED.
Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the
absence of organic disease. Dysfunctional uterine bleeding is the most common cause of
abnormal vaginal bleeding during a woman's reproductive years. Dysfunctional uterine
bleeding can have a substantial financial and quality-of-life burden. It affects women's
health both medically and socially.
The normal menstrual cycle is 28 days and starts on the first day of menses. During
the first 14 days (follicular phase) of the menstrual cycle, the endometrium thickens
under the influence of estrogen. In response to rising estrogen levels, the pituitary gland
secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which
stimulate the release of an ovum at the midpoint of the cycle. The residual follicular
capsule forms the corpus luteum.
After ovulation, the luteal phase begins and is characterized by production of
progesterone from the corpus luteum. Progesterone matures the lining of the uterus and
makes it more receptive to implantation. If implantation does not occur, in the absence of
human chorionic gonadotropin (hCG), the corpus luteum dies, accompanied by sharp
drops in progesterone and estrogen levels. Hormone withdrawal causes vasoconstriction
in the spiral arterioles of the endometrium. This leads to menses, which occurs
approximately 14 days after ovulation when the ischemic endometrial lining becomes
necrotic and sloughs.

Terms frequently used to describe abnormal uterine bleeding:

Menorrhagia - Prolonged (>7 d) or excessive (>80 mL daily) uterine bleeding

occurring at regular intervals

Metrorrhagia - Uterine bleeding occurring at irregular and more frequent than normal

Menometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular

and more frequent than normal intervals

Intermenstrual bleeding - Uterine bleeding of variable amounts occurring between

regular menstrual periods

Midcycle spotting - Spotting occurring just before ovulation, typically from

declining estrogen levels

Postmenopausal bleeding - Recurrence of bleeding in a menopausal woman at least 6

months to 1 year after cessation of cycles

Amenorrhea - No uterine bleeding for 6 months or longer
Dysfunctional uterine bleeding is a diagnosis of exclusion. It is ovulatory or

anovulatory bleeding, diagnosed after pregnancy, medications, iatrogenic causes, genital

tract pathology, malignancy, and systemic disease have been ruled out by appropriate
investigations. Approximately 90% of dysfunctional uterine bleeding cases result from
anovulation, and 10% of cases occur with ovulatory cycles.
Anovulatory dysfunctional uterine bleeding results from a disturbance of the
normal hypothalamic-pituitary-ovarian axis and is particularly common at the extremes
of the reproductive years. When ovulation does not occur, no progesterone is produced to
stabilize the endometrium; thus, proliferative endometrium persists. Bleeding episodes
become irregular, and amenorrhea, metrorrhagia, and menometrorrhagia are common.
Bleeding from anovulatory dysfunctional uterine bleeding is thought to result from
changes in prostaglandin concentration, increased endometrial responsiveness to
vasodilating prostaglandins, and changes in endometrial vascular structure.
In ovulatory dysfunctional uterine bleeding, bleeding occurs cyclically, and
menorrhagia is thought to originate from defects in the control mechanisms of
menstruation. It is thought that, in women with ovulatory dysfunctional uterine bleeding,

there is an increased rate of blood loss resulting from vasodilatation of the vessels
supplying the endometrium due to decreased vascular tone, and prostaglandins have been
strongly implicated. Therefore, these women lose blood at rates about 3 times faster than
women with normal menses.

United States
Dysfunctional uterine bleeding is one of the most often encountered gynecologic
problems. An estimated 5% of women aged 30-49 years will consult a physician each
year for the treatment of menorrhagia. About 30% of all women report having had

No cultural predilection is present with this disease state.
Morbidity is related to the amount of blood loss at the time of menstruation,
which occasionally is severe enough to cause hemorrhagic shock. Excessive
menstrual bleeding accounts for two thirds of all hysterectomies and most
endoscopic endometrial destructive surgery. Menorrhagia has several adverse effects,
including anemia and iron deficiency, reduced quality of life, and increased

healthcare costs.
Dysfunctional uterine bleeding has no predilection for race; however, black
women have a higher incidence of leiomyomas and, as a result, they are prone to

experiencing more episodes of abnormal vaginal bleeding.

Dysfunctional uterine bleeding is most common at the extreme ages of a
woman's reproductive years, either at the beginning or near the end, but it may occur
at any time during her reproductive life.
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the
first 2 years after the onset of menstruation, when their immature hypothalamicpituitary axis may fail to respond to estrogen and progesterone, resulting in
anovulation. Abnormal uterine bleeding affects up to 50% of perimenopausal
women. In the perimenopausal period, dysfunctional uterine bleeding may be an

early manifestation of ovarian failure causing decreased hormone levels or

responsiveness to hormones, thus also leading to anovulatory cycles. In patients who
are 40 years or older, the number and quality of ovarian follicles diminishes.
Follicles continue to develop but do not produce enough estrogen in response to FSH
to trigger ovulation. The estrogen that is produced usually results in late-cycle
estrogen breakthrough bleeding.
Patients often present






metrorrhagia, or menometrorrhagia. The amount and frequency of bleeding and the

duration of symptoms, as well as the relationship to the menstrual cycle, should be
established. Ask patients to compare the number of pads or tampons used per day in
a normal menstrual cycle to the number used at the time of presentation. The average
tampon or pad absorbs 20-30 mL or vaginal effluent. Personal habits vary greatly
among women; therefore, the number of pads or tampons used is unreliable. The
patient should be questioned about the possibility of pregnancy.
A reproductive history should always be obtained, including the following:
o Age of menarche and menstrual history and regularity
o Last menstrual period (LMP), including flow, duration, and presence of

Postcoital bleeding
Gravida and para
Previous abortion or recent termination of pregnancy
Contraceptive use, use of barrier protection, and sexual activity (including

vigorous sexual activity or trauma)

o History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following:
o Signs and symptoms of anemia or hypovolemia (including fatigue, dizziness,

and syncope)
Diabetes mellitus
Thyroid disease
Endocrine problems or pituitary tumors
Liver disease
Recent illness, psychological stress, excessive exercise, or weight change

o Medication usage, including exogenous hormones, anticoagulants, aspirin,

anticonvulsants, and antibiotics
o Alternative and complementary medicine modalities, such as herbs and
An international expert panel including obstetrician/gynecologists and
hematologists has issued guidelines to assist physicians to better recognize bleeding
disorders, such as von Willebrand disease, as a cause of menorrhagia and postpartum
hemorrhage and to provide disease-specific therapy for the bleeding disorder.
Historically, a lack of awareness of underlying bleeding disorders has led to
underdiagnosis in women with abnormal reproductive tract bleeding. The panel
provided expert consensus recommendations on how to identify, confirm, and
manage a bleeding disorder. If a bleeding disorder is suspected, evaluation for a
coagulation problem is required and consultation with a hematologist is suggested.
An underlying bleeding disorder should be considered when a patient has any of the
o Menorrhagia since menarche
o Family history of bleeding disorders
o Personal history of 1 or several of the following:
Notable bruising without known injury
Bleeding of oral cavity or GI tract without obvious lesion
Epistaxis >10 min duration (possibly necessitating packing or cautery)

o Vital signs, including postural changes, should be assessed. Initial evaluation
should be directed at assessing the patient's volume status and degree of anemia.
Examine for pallor and absence of conjunctival vessels to gauge anemia.
o An abdominal examination should be performed. Femoral and inguinal lymph
nodes should be examined. Stool should be evaluated for the presence of blood.
o Patients who are hemodynamically stable require a pelvic speculum, bimanual,
and rectovaginal examination to define the etiology of vaginal bleeding. A
careful physical examination will exclude vaginal or rectal sources of bleeding.
The examination should look for the following:
The vagina should be inspected for signs of trauma, lesions, infection, and

foreign bodies.
The cervix should be visualized and inspected for lesions, polyps, infection,

or intrauterine device (IUD).Bleeding from the cervical os

A rectovaginal examination should be performed to evaluate the cul-de-sac,

posterior wall of the uterus, and uterosacral ligaments.

o Uterine or ovarian structural abnormalities, including leiomyoma or fibroid
uterus, may be noted on bimanual examination.
o Patients with hematologic pathology may also have cutaneous evidence of
bleeding diathesis. Physical findings include petechiae, purpura, and mucosal
bleeding (eg, gums) in addition to vaginal bleeding.
o Patients with liver disease that has resulted in a coagulopathy may manifest
additional symptomatology because of abnormal hepatic function. Evaluate
patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice,
and asterixis.
o Women with polycystic ovary disease present with signs of hyperandrogenism,
including hirsutism, obesity, acne, palpable enlarged ovaries, and acanthosis
nigricans (hyperpigmentation typically seen in the folds of the skin in the neck,
groin, or axilla)
o Hyperactive and hypoactive thyroid can cause menstrual irregularities. Patients
may have varying degrees of characteristic vital sign abnormalities, eye findings,
tremors, changes in skin texture, and weight change. Goiter may be present.

o Systemic





hyperthyroidism, Cushing disease, liver disease, diabetes mellitus, and adrenal

and other endocrine disorders, can present as abnormal uterine bleeding.
o Pregnancy and pregnancy-related conditions may be associated with vaginal
o Trauma to the cervix, vulva, or vagina may cause abnormal bleeding.
o Carcinomas of the vagina, cervix, uterus, and ovaries must always be considered
in patients with the appropriate history and physical examination findings.
Endometrial cancer is associated with obesity, diabetes mellitus, anovulatory
cycles, nulliparity, and age older than 35 years.
o Other causes of abnormal uterine bleeding include structural disorders, such as
functional ovarian cysts, cervicitis, endometritis, salpingitis, leiomyomas, and
adenomyosis. Cervical dysplasia or other genital tract pathology may present as
postcoital or irregular bleeding.

o Polycystic ovary disease results in excess estrogen production and commonly

presents as abnormal uterine bleeding.
o Primary coagulation disorders, such





myeloproliferative disorders, and immune thrombocytopenia, can present with

o Excessive exercise, stress, and weight loss cause hypothalamic suppression
leading to abnormal uterine bleeding due to disruption along the hypothalamuspituitary-ovarian pathway.
o Bleeding disturbances are common with combination oral contraceptive pills as
well as progestin-only methods of birth control. However, the incidence of
bleeding decreases significantly with time. Therefore, only counseling and
reassurance are required during the early months of use.
o Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding
for the first few cycles after placement and intermittent spotting subsequently.
The progesterone impregnated IUD (Mirena) is associated with less
menometrorrhagia and usually results in secondary amenorrhea.


Cervical Cancer
Early Pregnancy Loss in Emergency Medicine
Emergent Management of Abruptio Placentae
Emergent Management of Ectopic Pregnancy
Emergent Treatment of Endometriosis
Endocervical Polyp
Endometrial Carcinoma
Endometrial Polyp
Estrogen Therapy
Fibroids (leiomyomata)
Foreign body

Hydatidiform Mole
Iatrogenic Cushing Syndrome
Intrauterine devices
Liver disease
Mullerian Duct Anomalies
Oral contraceptives
Ovarian Cysts
Pelvic Inflammatory Disease
Placenta Previa
Platelet Disorders
Polycystic Ovarian Syndrome
Renal disease
Vascular Surgery for Arteriovenous Malformations
von Willebrand Disease


Laboratory Studies
o When evaluating a woman of reproductive age with vaginal bleeding, pregnancy
must always be ruled out by urine or serum human chorionic gonadotropin.
o In a patient with any hemodynamic instability, excessive bleeding, or clinical
evidence of anemia, a complete blood count is essential.
o Coagulation studies should be considered when indicated by the history or
physical examination findings and in patients with underlying liver disease or
other coagulopathies.
o In patients with suspected endocrine disorders, other laboratory studies such as
thyroid function tests and prolactin levels may be helpful, although these results
may not be available from the ED.

Imaging Studies
o Pelvic ultrasonography is an important imaging modality for nonpregnant
patients with abnormal vaginal bleeding. It may determine the etiology of the

bleeding such as a fibroid uterus, endometrial thickening, or a focal mass.

Thickened endometrium may indicate an underlying lesion or excess
estrogen and may be suggestive of malignancy.
An endometrial stripe measuring less than 4 mm thick is unlikely to
have endometrial hyperplasia or cancer, and biopsy is often considered
unnecessary before treatment.
Women with a normal endometrial stripe (512 mm) may require
biopsy, particularly if they have risk factors for endometrial cancer.
When the endometrial stripe is larger than 12 mm, a biopsy should be

Depending on the urgency to determine the etiology of bleeding and on the
reliability of outpatient follow-up, ultrasonography may be deferred for
outpatient evaluations because for the majority of nonpregnant patients,

ultrasonographic findings do not immediately affect ED decision-making.

o Transvaginal ultrasonography may be particularly helpful in further delineating
ovarian cysts and fluid in the cul-de-sac.
o Computed tomography is used primarily for evaluation of other causes of acute
abdominal or pelvic pain.
o Magnetic resonance imaging is used primarily for cancer staging.

o Before instituting therapy, many consulting gynecologists perform endometrial
sampling or biopsy to diagnose intrauterine pathology and to exclude
endometrial malignancy.
o Endometrial biopsy is indicated for the following patients with abnormal uterine
Women older than 35 years
Obese patients
Women who have prolonged periods of unopposed estrogen stimulation
Women with chronic anovulation
o Hysteroscopy is the definitive way to detect intrauterine lesions. It offers a more
complete examination of the surface of the endometrium. However, it is usually
reserved for treating lesions that were detected by other less invasive means.


Emergency Department Care

o Hemodynamically unstable patients with uncontrolled bleeding and signs of
significant blood loss should have aggressive resuscitation with saline and blood
as with other types of hemorrhagic shock.
Evaluate ABCs and address the priorities.
Initiate 2 large-bore intravenous lines (IVs), oxygen, and cardiac monitor.
If bleeding is profuse and the patient is unresponsive to initial fluid
management, consider administration of IV conjugated estrogen (Premarin)

25 mg IV every 4-6 hours until the bleeding stops.

In women with severe, persistent uterine bleeding, an immediate dilation

and curettage (D&C) procedure may be necessary.

o Combination oral contraceptive pills may be used in women who are not
pregnant and have no anatomic abnormalities. An oral contraceptive with 35
mcg of ethinyl estradiol can be taken twice a day until the bleeding stops for up
to 7 days, at which time the dose is decreased to once a day until the pack is
completed. They provide the additional benefits of reducing dysmenorrhea and
providing contraception. Side effects include nausea and vomiting.
o Progesterone alone can be used to stabilize an immature endometrium. It is
usually successful in the treatment of women with anovulatory dysfunctional
uterine bleeding (DUB) because these women have unopposed estrogen
stimulation. Medroxyprogesterone acetate 10 mg is taken orally once daily for
10 days, followed by withdrawal bleeding 3-5 days after completion of the
course. Currently, there is not enough evidence comparing the effect of either
progesterone alone or in combination with estrogens for the treatment of
dysfunctional uterine bleeding.
o Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally effective for the
treatment of dysfunctional uterine bleeding and dysmenorrhea. NSAIDs inhibit
cyclooxygenase in the arachidonic acid cascade, thus inhibiting prostaglandin
synthesis and increasing thromboxane A2 levels. This leads to vasoconstriction
and increased platelet aggregation. These medications may reduce blood loss by
20-50%. NSAIDs are most effective if used with the onset of menses or just
prior to its onset and continued throughout its duration.
o Danazol creates a hypoestrogenic and hyperandrogenic environment, which
induces endometrial atrophy resulting in reduced menstrual loss. Side effects

include musculoskeletal pain, breast atrophy, hirsutism, weight gain, oily skin,
and acne. Because of the significant androgenic side effects, this drug is usually
reserved as a second-line treatment for short-term use prior to surgery.
o Gonadotropin-releasing hormone agonists may be helpful for short-term use in
inducing amenorrhea and allowing women to rebuild their red blood cell mass.
They produce a profound hypoestrogenic state similar to menopause. Side
effects include menopausal symptoms and bone loss with long-term use.
o Tranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly
inhibiting plasminogen. It diminishes fibrinolytic activity within endometrial
vessels to prevent bleeding. It has been shown effective in reducing bleeding in
up to half of women with dysfunctional uterine bleeding. Tranexamic acid is not
approved for the treatment of dysfunctional uterine bleeding in the United

Other Treatment Considerations

The American College of Obstetricians and Gynecologists offers guidelines
regarding the treatment of abnormal uterine bleeding associated with ovulatory
dysfunction; they include the following level B recommendations and conclusions
(ie, those based on limited or inconsistent scientific evidence) :
o The levonorgestrel intrauterine device (IUD) has been shown to be effective in
treating abnormal uterine bleeding and should be considered for all age groups.
o Medical treatment options for abnormal uterine bleeding associated with
ovulatory dysfunction include progestin therapy and combined hormonal
o Women who have completed childbearing, in whom medical therapy has
failed, or who have contraindications to medical therapy are candidates for
hysterectomy without cervical preservation
o Because abnormal uterine bleeding associated with ovulatory dysfunction is an
endocrinologic abnormality, the underlying disorder should be treated
medically rather than surgically; surgical therapy is rarely indicated for the
treatment of abnormal uterine bleeding associated with ovulatory dysfunction
unless medical therapy fails, is contraindicated, or is not tolerated by the

patient, or unless the patient has significant, concomitant intracavitary lesions

A study by Ammerman and Nelson indicated that outpatient treatment
combining an injection of depo- medroxyprogesterone acetate with oral
medroxyprogesterone can stop acute abnormal uterine bleeding. In the prospective,
single-arm, pilot clinical trial, 48 nonpregnant, premenopausal women who were
experiencing abnormal uterine bleeding were given an intramuscular injection of
150 mg of depo-medroxyprogesterone acetate and were prescribed 20 mg of
medroxyprogesterone, which was to be taken orally every 8 hours for 3 days.
Within 5 days, all 48 patients had stopped bleeding, with the mean time to bleeding
cessation being 2.6 days.

o Seek an emergency






hemodynamic stabilization. If parenteral therapy does not completely arrest

vaginal bleeding in the hemodynamically unstable patient, an emergency D&C
may be warranted.
o Consultation with or urgent referral to a gynecologist for surgical treatment may
be necessary for patients who do not desire fertility and in whom medical
therapy fails. Both endometrial ablation and hysterectomy are effective
treatments in women with dysfunctional uterine bleeding with comparable
patient satisfaction rates.
Endometrial ablation may be performed using laser, electrocautery, or
rollerball. Amenorrhea is seen in approximately 35% of women treated, and
decreased flow is seen in another 45%; although, treatment failures increase
with time following the procedure due to endometrial regeneration. A
substantial number of patients receiving endometrial ablation require

reoperation (30% by 48 months).

Hysterectomy is the most effective treatment for bleeding. However, it is
associated with more frequent and severe adverse events compared with
either conservative medical or ablation procedures. Operating time,
hospitalization, recovery times, and costs are also greater. Hence,
hysterectomy is reserved for selected patient populations.

Medication Summary
The goals of pharmacotherapy are to control the bleeding, reduce morbidity, and prevent
o Steroid hormones
Class Summary
These agents may help control bleeding. Some of them are used when bleeding is
profuse and the patient is unresponsive to initial fluid management.
Ethinyl estradiol 35 g and norethindrone 1mg (Necon 1/35, Nortrel 1/35,
Ortho-Novum 1/35, Norinyl 1 + 35)
Reduces secretion of LH and FSH from pituitary by decreasing amount of
GnRH. Contraceptive pills containing estrogen and progestin have been
advocated for nonsmoking patients with DUB who desire contraception.
Therapy also used to treat acute hemorrhagic uterine bleeding but not as
effective as other treatments perhaps because may take longer to induce
endometrial proliferation when progestin is present.
Suggested mechanisms by which hormonal therapy might affect bleeding
include improvement in coagulation, alterations in the microvascular circulation,
and improvements in endothelial integrity. In long-term management of DUB,

combination oral contraceptives are very effective.

Synthetic steroid analog, derived from




antigonadotropic activity (inhibits LH and FSH) and weak androgenic action

without adverse virilizing and masculinizing effects. Increases levels of C4
component of the complement. May push the resting hematopoietic stem cells
into cycle, making them more responsive to differentiation by hematopoietic
growth factors. May also stimulate endogenous secretion of erythropoietin.
May impair clearance of immunoglobulin-coated platelets and decreases
autoantibody production.
Certain androgenic preparations have been used historically to treat mild-tomoderate bleeding, particularly in ovulatory patients with abnormal uterine

bleeding. These regimens offer no real advantage over other regimens and might
cause irreversible signs of masculinization in the patient. They seldom are used
for this indication today.
Use of androgens might stimulate erythropoiesis and clotting efficiency.

Androgens alter endometrial tissue so that it becomes inactive and atrophic.

Estrogens, conjugated (Premarin)
Causes vasospasm of uterine arteries and initiates several coagulationrelated functions, which decrease uterine bleeding. Use in pharmacologic doses
also causes rapid growth of endometrial tissue over denuded and raw epithelial

Medroxyprogesterone acetate (Provera)
DOC for most patients with anovulatory DUB. After acute bleeding episode
controlled, can be used alone in patients with adequate amounts of endogenous
estrogen to cause endometrial growth. Progestin therapy in adolescents produces
regular cyclic withdrawal bleeding until positive feedback system matures.
Progestins stop endometrial growth and support and organize endometrium to
allow organized sloughing after their withdrawal. Bleeding ceases rapidly
because of an organized slough to the basalis layer. These drugs usually do not
stop acute bleeding episodes, yet produce a normal bleeding episode following

their withdrawal.
o Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Class Summary
These agents can decrease DUB through inhibition of prostaglandin synthesis.
NSAIDs only need to be taken during menstruation.
Naproxen (Naprosyn, Aleve, Naprelan)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by
decreasing activity of cyclooxygenase, which is responsible for prostaglandin
synthesis. NSAIDs decrease intraglomerular pressure and decrease proteinuria.
o Gonadotropin Releasing Hormone Analog
Class Summary
These agents are generally used for short-term use to induce amenorrhea and allow
the rebuilding of the red blood cell mass.
Leuprolide acetate (Lupron, Eligard)
Suppresses ovarian and testicular steroidogenesis by decreasing LH and
FSH levels.
Works by reducing concentration of GnRH receptors in the pituitary via

receptor down regulation and induction of postreceptor effects, which suppress

gonadotropin release. After an initial gonadotropin release associated with rising
estradiol levels, gonadotropin levels fall to castrate levels, with resultant
hypogonadism. This form of medical castration is very effective in inducing
amenorrhea, thus breaking ongoing cycle of abnormal bleeding in many
anovulatory patients. Because prolonged therapy with this form of medical
castration is associated with osteoporosis and other postmenopausal side effects,
many practitioners add a form of low-dose hormonal replacement to the
regimen. Because of the expense of these drugs, they usually are not used as a
first-line approach but can be used to achieve short-term relief from a bleeding
problem, particularly in patients with renal failure or blood dyscrasia.


Further Outpatient Care

Most patients with abnormal uterine bleeding without hemodynamic compromise
should be referred to a gynecologist for definitive management on an outpatient

Further Inpatient Care
Patients with severe, acute abnormal uterine bleeding and hemodynamic instability

will require urgent gynecologic consultation and hospitalization.

Inpatient & Outpatient Medications
Patients with bleeding heavy enough to decrease hematocrit may be given ferrous
sulfate tablets (325 mg tid).Hormone regimens, including combination oral
contraceptives and cyclic progestins, may be continued for several months under the

supervision of the consulting gynecologist.

o Anemia (may become severe)
o Adenocarcinoma of the uterus (if prolonged, unopposed estrogen stimulation)
Hormonal contraceptives reduce blood loss by 40-70% when used long term.
Although medical therapy is generally used first, over half of women with
menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist.[2]

Patient Education
o Instruct patients to continue prescribed medications, although bleeding may still
be occurring during the early part of the cycle. Also, patients should be told to
expect menses after cessation of the regimen.
o Young patients with small amounts of irregular bleeding need reassurance and
observation only prior to instituting a drug regimen. Express to patients that
pharmacologic intervention will not be necessary once menstrual cycles become
o Discuss ways the patient can avoid prolonged emotional stress and maintain a
normal body mass index.
o For excellent patient education resources, visit eMedicineHealth's Women's
Health Center. Also, see eMedicineHealth's patient education articles Vaginal
Bleeding and Painful Ovulation (Mittelschmerz).