drugs given yo control bleeding in Abnormal uterine bleeding
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"abnormal uterine bleeding"[MeSH Terms] AND "drug therapy"[MeSH Terms]
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Drugs Used to Control Bleeding in Abnormal Uterine Bleeding (AUB)
AUB management depends on whether the bleeding is anovulatory (estrogen-breakthrough, common in PCOS, perimenarchal, perimenopausal) or ovulatory (structural/hormonal). Below is a systematic drug-class overview drawn from Rosen's Emergency Medicine, Goldman-Cecil Medicine, Berek & Novak's Gynecology, and Bailey & Love's Surgery.
1. Hormonal Agents
A. Combined Oral Contraceptive Pills (COCPs)
The most widely used first-line treatment for both acute and chronic AUB.
- Dose (acute bleeding): Monophasic pill containing <35 µg ethinyl estradiol
- 1 pill three times daily for 7 days, OR
- 1 pill twice daily for 5 days, then once daily until the pack is finished
- Mechanism: Progestin component stabilizes the endometrium; estrogen stops bleeding rapidly
- Chronic prevention: Cyclic OCP use after acute episode prevents recurrence
- Contraindications: Women <35 years who smoke; history of DVT/PE, breast cancer, liver disease, ischemic heart disease, uncontrolled hypertension, pregnancy
B. Progestin-Only Therapy
Used when estrogen is contraindicated, or for anovulatory bleeding.
| Drug | Dose | Notes |
|---|---|---|
| Medroxyprogesterone acetate (MPA) | 5-10 mg PO daily for 10 days (chronic) or 20 mg three times daily for 7 days (acute) | Induces endometrial shedding on withdrawal |
| Norethindrone | 5 mg daily | Alternative to MPA for cyclic therapy |
- Withdrawal bleeding occurs after stopping; patient then transitions to cyclic hormonal therapy
- Contraindications: Active/past DVT/PE, liver disease, breast cancer
C. Conjugated Equine Estrogens (CEE) - IV
Used for acute, profuse anovulatory bleeding to stop bleeding rapidly.
- Dose: 25 mg IV every 4-6 hours until bleeding stops (up to 24 hours; max ~3 doses)
- Mechanism: Promotes endometrial hemostasis and stabilizes fragile endometrial vessels
- Always follow with progestin (MPA 5-10 mg) started simultaneously to stabilize the endometrium
- After bleeding stops, transition to cyclic OCP for at least 3 cycles
- Contraindications: Active/past thromboembolic disease, breast cancer, liver disease
D. Levonorgestrel-Releasing IUD (LNG-IUD, e.g., Mirena)
Highly effective for ovulatory AUB and heavy menstrual bleeding (menorrhagia).
- Releases 20 µg levonorgestrel/day locally into the uterine cavity
- Markedly reduces menstrual blood loss (up to 90%) over time
- Also effective for dysmenorrhea
- Preferred long-term option when contraception is also desired
2. Antifibrinolytic Agents
Tranexamic Acid
- Dose: 1.3 g PO every 6-8 hours for up to 5 days (or 650 mg x2-3 doses)
- Mechanism: Inhibits plasminogen activators, preventing fibrin clot dissolution in endometrial vessels - reduces blood loss by ~50%
- Used specifically for ovulatory AUB / heavy menstrual bleeding
- Contraindications: Current or past thromboembolic disease, acquired impaired color vision
- Important: Do NOT combine with combined oral contraceptive pills (additive thrombotic risk)
3. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
Useful for ovulatory AUB - reduce prostaglandin-mediated vasodilation and blood loss by 20-50%.
| Drug | Dose | Duration |
|---|---|---|
| Ibuprofen | 200-400 mg three or four times daily | 5 days |
| Mefenamic acid | 500 mg three times daily | 4-5 days or until bleeding stops |
| Naproxen | 500 mg initially, then 250 mg three or four times daily | 5 days |
- Best started at the onset of bleeding or just before
- Contraindications: Advanced renal disease; use with caution in GI ulcer history or bleeding disorders
4. GnRH Agonists / Antagonists (for AUB due to Fibroids)
For women with AUB caused by uterine fibroids (leiomyomas):
- Elagolix 300 mg twice daily - GnRH antagonist, oral
- Relugolix 40 mg daily - GnRH antagonist (also combined with estradiol/norethindrone as Myfembree)
- Create a hypoestrogenic state, reducing fibroid size and associated bleeding
- Used as a bridge to surgery or as standalone medical management
Summary by Clinical Scenario
| Scenario | First-Line Drug(s) |
|---|---|
| Acute profuse anovulatory bleeding | IV Conjugated estrogens + progestin, then OCP |
| Anovulatory AUB (chronic) | Combined OCP or cyclic progestin (MPA/norethindrone) |
| Ovulatory AUB / heavy menstrual bleeding | NSAIDs + tranexamic acid; LNG-IUD long-term |
| AUB due to uterine fibroids | GnRH antagonists (elagolix, relugolix) |
| Anovulatory bleeding (PCOS) | OCP or cyclic progestin |
| Adolescent anovulatory bleeding | OCP (low-dose) |
Key points:
- Exclude pregnancy and coagulopathy (von Willebrand disease) before initiating medical therapy - Goldman-Cecil Medicine
- Anovulatory bleeding (75% of AUB cases) is mostly due to unopposed estrogen stimulating the endometrium - Goldman-Cecil Medicine
- Dilation and curettage is NOT an effective long-term treatment for AUB - Berek & Novak's Gynecology
- Hysterectomy is reserved for failure of all medical therapies - Berek & Novak's Gynecology, p. 1411
- Endometrial ablation is increasingly used but is not 100% effective; medical management remains first line - Goldman-Cecil Medicine
Sources: Rosen's Emergency Medicine (Table 30.1), Goldman-Cecil Medicine, Berek & Novak's Gynecology, Bailey & Love's Surgery 28th Ed.
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