Urgent considerations

See Differentials for more details

An episode of heavy bleeding may warrant urgent intervention to prevent further blood loss.[1]

Evaluate the patient for signs of hypovolaemia and haemodynamic instability and establish large bore intravenous access if either of these are present. Physical examination should be performed to confirm that the bleeding is uterine and to establish the aetiology of the bleeding, if possible.[18]

Intravenous fluid resuscitation and blood transfusion should be administered to stabilise the patient.[18] Tranexamic acid should also be considered as soon as possible in anyone with severe vaginal bleeding.[19][20]

Initial laboratory testing should include full blood count, blood type and crossmatch, and pregnancy testing. Pregnancy complications, including ectopic pregnancy or threatened abortion, may present as acute abnormal uterine bleeding.[21] 

Hormonal therapy with intravenous conjugated equine oestrogen, combined oral contraceptives, or oral progestins is the medical treatment of choice.[18] Acute haemorrhage can be urgently managed by uterine tamponade using a Foley catheter inserted into the uterine cavity.[18] Emergent exploratory surgery may be required for control of bleeding in patients with hypotension or shock from massive haemorrhage.

Most heavy menstrual bleeding does not present as a single torrential episode, but chronic iron loss through heavy menstrual bleeding may present with acute symptoms apparently disproportional to the blood loss associated with the presenting bleed. In this context, symptoms that may indicate the need for prompt blood transfusion include dizziness, syncope, headache, dyspnoea, tachycardia, arrhythmia, cardiac murmur, angina, and haemodynamic instability.[22] Iron deficiency may frequently present with exacerbations of coexisting chronic conditions that also require prompt management (e.g., acutely worsening heart failure).[22]

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