Background: Acute uterine bleeding is a common clinical presentation in nonpregnant women of reproductive age, and its optimal treatment is unclear. Surgical options include dilation and curettage, uterine artery embolization, and hysterectomy. Medical therapies include estrogen therapy, progestin therapy, or combination oral contraceptives. Few scientific data exist on the effectiveness, adverse effects, or patient satisfaction associated with these approaches. Munro and colleagues compared the two most popular medical treatments (i.e., oral progestins and mono-phasic combination oral contraceptives) in a randomized controlled trial of young women with nongestational acute uterine bleeding.
The Study: The study included women presenting to an emergency department, gynecology urgent care center, or outpatient clinic of a large health plan because of acute uterine bleeding. Study participants were at least 18 years of age, not pregnant, premenopausal, and hemodynamically stable with a hemoglobin concentration of at least 8 g per dL (80 g per L). Patients with structural defects that could account for bleeding were excluded by physical examination, augmented by transvaginal ultrasonography if appropriate. Other exclusion factors included use of an intrauterine device, recent uterine surgery or infertility treatment, and any contraindication to the study medications. Patients were screened by a questionnaire addressing demographic, medical, and gynecologic data. Patients also received physical and gynecologic examinations and hemoglobin concentration and pregnancy testing. Other tests were performed at the discretion of the patients' physicians.
Participants were randomly allocated to treatment with oral medroxyprogesterone acetate (Provera; 20 mg three times daily for seven days) or a combination oral contraceptive (three times daily for seven days). After the initial seven days, treatment continued with 20 mg daily of medroxyprogesterone acetate or one combination oral contraceptive tablet daily for three weeks. Patients recorded daily use of the medications, pad and tampon counts, symptoms (e.g., cramping, bloating), satisfaction with treatment, and perceived adverse effects from treatment. Patients were reassessed after two and four weeks.
Results: The 20 women in each group did not differ significantly in any important variable, although the mean duration of bleeding before randomization was 15.5 days in the progestin group compared with eight days in the combination group. The average age of participants was about 43 years, the mean body mass index was about 30 kg per m2, and the mean hemoglobin concentration was 12.4 to 12.8 g per dL (124 to 128 g per L). At four weeks, complete data were available for 17 women (85 percent) in the progestin group and for 16 women (80 percent) in the combination group. In both groups, the median time to cessation of bleeding was three days. At the two-week visit, 76 percent of women treated with the progestin and 88 percent treated with the combination oral contraceptive reported cessation of bleeding. The only surgery performed was dilation and curettage in one patient in the combination group. The groups did not differ in symptom scores for nausea, cramping, or bloating or in overall patient satisfaction scores.
Conclusion: Although this small study had some difficulties with compliance and follow-up, the authors conclude that both regimens provided effective and acceptable therapy for acute uterine bleeding in stable, nonpregnant patients. The incidence and severity of adverse effects were low, and surgical interventions were avoided. The authors call for larger randomized studies to confirm their results.