Ongoing heavy bleeding requiring frequent pad changes
Symptomatic anemia
Syncope
Chest pain
Dyspnea
Transfusion requirement
Suspected malignancy with significant bleeding
Severe infection or PID with systemic features
ICU criteria
Refractory hypotension
Massive transfusion
Active hemorrhage despite initial hemostatic therapy
Discharge and follow-up
Discharge criteria
Stable vitals over observation period
Bleeding controlled to manageable level
Hemoglobin stable on repeat when indicated
Reliable follow-up within appropriate timeframe
Follow-up timing
Postmenopausal bleeding
Urgent gynecology
Endometrial biopsy planning
Reproductive age AUB
Gynecology or primary care within weeks
Ultrasound and labs review plan
Treatment
Initial resuscitation
Hemorrhage stabilization bundle
Crystalloid judicious use
Bridge while blood prepared
Avoid dilutional coagulopathy in massive hemorrhage
RBC transfusion
If hemodynamic instability from bleeding
If symptomatic anemia with ongoing bleeding
Platelets and plasma support per massive hemorrhage protocol
If thrombocytopenia or coagulopathy
If large volume transfusion
Tranexamic acid early in life-threatening bleeding
1 g IV over 10 minutes
Then 1 g IV over 8 hours if ongoing bleeding
Medical hemostatic therapy for abnormal uterine bleeding
Hormonal acute control options
High-dose combined oral contraceptive regimen
Ethinyl estradiol 30 to 35 mcg with progestin
1 tablet PO every 6 hours for 24 hours
Then 1 tablet PO every 8 hours for 3 days
Then 1 tablet PO daily
Contraindications screen
VTE history
Migraine with aura
Severe hypertension
High-dose progestin regimen
Medroxyprogesterone acetate 20 mg PO every 8 hours for 7 days
Then 20 mg PO daily for 21 days
Useful when estrogen contraindicated
Norethindrone acetate 5 mg PO every 6 hours for 7 days
Then taper per outpatient plan
Alternative progestin strategy
IV estrogen for refractory severe uterine bleeding with gynecology involvement
Conjugated estrogen 25 mg IV every 4 to 6 hours
Maximum 24 hours total
Transition to oral hormonal regimen after control
Thrombosis risk mitigation
Avoid in high VTE risk
Consider hematology input if needed
Non-hormonal therapy
Antifibrinolytic and anti-inflammatory options
Tranexamic acid for stable heavy bleeding
1 g PO three times daily during heavy days
Avoid in active thrombosis
NSAIDs for ovulatory heavy menstrual bleeding
Ibuprofen 400 mg PO every 6 hours with food
Naproxen 500 mg PO once then 250 mg PO every 6 to 8 hours
Iron repletion when anemia present
Ferrous sulfate 325 mg PO every other day
IV iron pathway when oral not tolerated or severe deficiency
Procedural and definitive hemorrhage control
Mechanical and procedural options
Intrauterine balloon tamponade for uncontrolled uterine bleeding
Foley catheter with sterile water inflation
Gynecology guidance and monitoring
Dilation and curettage or hysteroscopy for persistent bleeding
Suspected retained products or focal lesion
Hemodynamic compromise despite medical therapy
Uterine artery embolization in select refractory cases
Interventional radiology pathway
Structural bleeding source or failed medical therapy
Treat the underlying cause
Infection related bleeding
Cervicitis treatment per local STI guideline
Ceftriaxone IM single dose regimen per local dosing
Doxycycline regimen per local dosing
PID treatment per local guideline
Broad coverage outpatient or inpatient pathway based on severity
Admission for systemic illness or inability to tolerate PO
Anticoagulant associated bleeding
Hold anticoagulant and coordinate with prescriber
Risk benefit discussion
Restart planning after control
If life-threatening bleeding, reversal pathway per agent
PCC based strategy for warfarin or factor Xa inhibitors per local protocol
Vitamin K for warfarin based on INR and severity
Coagulopathy
Hematology involvement when suspected inherited bleeding disorder
Desmopressin for known type 1 von Willebrand disease per protocol
Factor concentrate pathway for severe disease
Special Populations
Pregnancy
Pregnancy overlap safeguards
Beta hCG obtained even when pregnancy denied
If positive, pregnancy bleeding differential
Ectopic pregnancy
Miscarriage spectrum
If positive and unstable, urgent ultrasound and gynecology
Resuscitation continues in parallel
Rh immune globulin decisions per gestational age and Rh status
Geriatric
Postmenopausal bleeding pathway
Malignancy until proven otherwise
Cervical and endometrial cancer prioritization
Expedited gynecology follow-up
Ultrasound interpretation emphasis
Endometrial thickness evaluation
Persistent bleeding triggers biopsy even with reassuring imaging
Medication risks
Higher thrombotic risk with estrogen
Polypharmacy and anticoagulants more common
Pediatrics
Adolescent heavy menstrual bleeding considerations
Anovulatory cycles common early after menarche
Irregular heavy bleeding pattern
Iron deficiency risk high
Bleeding disorder screening priority
von Willebrand disease prevalence enrichment in this group
Early hematology referral pathway
Weight-based medication safety
NSAID dosing by weight and renal function
Hormonal therapy contraindication screening
Background
Epidemiology
Abnormal uterine bleeding overview
Common ED presentation across reproductive lifespan
Peaks in adolescence and perimenopause due to anovulation patterns
Postmenopausal bleeding carries higher malignancy risk than reproductive age bleeding
Pathophysiology
Bleeding mechanisms by category
Structural lesions
Increased surface area and vascularity in fibroids
Fragile tissue in polyps and malignancy
Ovulatory dysfunction
Unopposed estrogen leading to endometrial proliferation
Unstable endometrium and breakthrough bleeding
Coagulopathy and iatrogenic
Impaired clot formation or platelet function
Anticoagulant effect unmasking baseline heavy menses
Therapeutic Considerations
Medication strategy principles
Acute control prioritized over definitive diagnosis in unstable bleeding
Estrogen raises endometrial stability rapidly but increases thrombosis risk
Progestins stabilize endometrium when estrogen contraindicated
Tranexamic acid reduces fibrinolysis and can reduce bleeding volume
Evidence framing for ED care
Hormonal regimens supported by gynecology consensus and observational data
Tranexamic acid supported by broader hemorrhage evidence and gynecology use patterns
ACEP Level C style framing
Early pregnancy test in all reproductive potential patients with vaginal bleeding
Early gynecology consultation for hemodynamic instability
Patient Discharge Instructions
copy discharge instructions
Discharge instructions for vaginal bleeding
Expected course
Light bleeding and spotting may continue for a few days depending on cause and treatment
Medication effect may take 24 to 48 hours to reduce flow
Medication use
Take prescribed hormones exactly as directed
Avoid NSAIDs if on anticoagulants or kidney disease unless approved
Iron as prescribed for anemia
Return now to ED
Soaking 1 pad per hour for 2 consecutive hours
Fainting or near fainting
Chest pain
Trouble breathing
Severe or worsening pelvic pain
Fever
Positive pregnancy test or pregnancy concern
Follow-up
Gynecology or primary care appointment arranged
Ultrasound and lab review plan confirmed
Postmenopausal bleeding requires urgent follow-up even if bleeding stops
References
Clinical guidelines and consensus
Key guidance sources
FIGO PALM COEIN classification for abnormal uterine bleeding
Standardized etiologies for AUB
Structural versus non-structural framework
ACOG guidance on acute abnormal uterine bleeding management
High-dose hormonal regimens as first-line for many stable patients
IV estrogen option for severe bleeding with appropriate risk screening
NICE guidance on heavy menstrual bleeding
Stepwise medical therapy options
Imaging and referral pathways for structural causes
Evidence-based reviews and emergency care references
Emergency medicine and gynecology reference standards
Pregnancy testing in reproductive potential patients with vaginal bleeding
Widely adopted emergency care standard
Risk reduction for missed ectopic pregnancy
Transvaginal ultrasound as first-line imaging for suspected uterine pathology
Highest yield for endometrial and adnexal evaluation
Doppler adjunct for torsion concern
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.