›Massive transfusion protocol local protocol dependent
›Packed red blood cells if
›Hemodynamic instability with bleeding
›Hemoglobin < 70 g/L with symptoms
›Hemostatic medication options for heavy uterine bleeding
›Tranexamic acid IV 1 g over 10 minutes
›Repeat 1 g after 30 minutes if ongoing severe bleeding local protocol dependent
›Avoid if active arterial or venous thrombosis
›High dose combined oral contraceptive regimen local protocol dependent
›Avoid if migraine with aura
›Avoid if active thromboembolism
›High dose progestin regimen local protocol dependent
›Option if estrogen contraindicated
›Adherence critical
›Pain and nausea control
›Acetaminophen 1000 mg PO
›Ondansetron ODT 4 mg
Diagnostic sequencing
›Immediate diagnostics
›Beta hCG
›CBC
›Type and screen
›Targeted diagnostics
›STI NAAT if cervicitis or PID concern
›TSH if ovulatory dysfunction suspected
›Ultrasound if structural cause suspected or persistent bleeding
Etiology specific treatment
›Cervicitis and PID treatment local protocol dependent
›Ceftriaxone IM dosing local protocol dependent
›Doxycycline dosing local protocol dependent
›Anticoagulant associated bleeding
›Anticoagulant hold decision with prescribing indication context
›Reversal agents local protocol dependent
Reassessment loop
›Reassessment timing
›Repeat vitals every 15 to 30 minutes if moderate bleeding
›Repeat pelvic bleeding assessment after interventions
›Escalation triggers
›Worsening tachycardia
›New hypotension
›Ongoing pad soaking despite therapy
17Disposition/dispo19
Admission and higher level of care criteria
›ICU or resuscitation bay criteria
›Ongoing hemorrhagic shock
›Transfusion requirement with continued bleeding
›Inpatient admission criteria
›Hemoglobin < 80 g/L with ongoing bleeding
›Requires procedural intervention
›Suspected malignancy needing urgent workup
›PID with systemic illness
Observation and discharge criteria
›Observation pathway criteria
›Moderate bleeding requiring serial hemoglobin
›Uncertain trajectory after initial therapy
›Discharge criteria
›Hemodynamically stable
›Bleeding controlled or clearly improving
›Hemoglobin stable for clinical context
›Reliable follow up within 72 hours when needed
Follow up timing
›Outpatient follow up
›Gynecology within 1 to 2 weeks for persistent AUB
›Urgent within 72 hours for high risk features without admission
18Discharge Instructions/di18
Copy discharge instructions
›Vaginal bleeding evaluated and pregnancy test negative
›Bleeding may be from hormonal or uterine causes, but some causes need follow up testing
›Return to the emergency department now for
›Fainting or near fainting
›Chest pain
›Shortness of breath
›Fever
›Severe worsening pelvic pain
›Soaking 1 pad per hour for 2 hours
›Medications
›Take prescribed medications exactly as directed
›Avoid NSAIDs if on blood thinners unless told otherwise
›Activity
›Avoid intercourse until bleeding stops and infection ruled out if discharge or pelvic pain present
›Avoid heavy exertion if lightheaded
›Follow up
›Follow up with primary care or gynecology within recommended timeframe
›If age 45 years or older or postmenopausal, endometrial evaluation may be needed
19References/r15
Guidelines and key sources
›ACOG Practice Bulletin on abnormal uterine bleeding, evaluation and management, year varies local protocol dependent
›PALM COEIN framework
›Endometrial sampling indications
›ACOG guidance on management of acute abnormal uterine bleeding in nonpregnant reproductive aged patients, year varies local protocol dependent
›Medical therapy options
›Escalation to procedural management
›NICE guideline on heavy menstrual bleeding, year varies local protocol dependent
›First line investigations
›Treatment options and sequencing
›Society of Gynecologic Oncology and major society statements on postmenopausal bleeding and endometrial cancer evaluation, year varies local protocol dependent
›Ultrasound and endometrial thickness use
›Biopsy thresholds and follow up
›CDC STI Treatment Guidelines, cervicitis and PID management, year varies local protocol dependent
›Recommended regimens
›Follow up and partner management
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.