Review Note

One of your patients with polycystic ovarian syndrome presents to the emergency room complaining of prolonged, heavy vaginal bleeding. She is 26 years old and has never been pregnant. She was taking birth control pills to regulate her periods until 4 months ago. She stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding & days ago. She has been doubling up on superabsorbant sanitary napkins 5 to 6 times daily since the bleeding began. On arrival at the emergency room, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her standing blood pressure is 108/66 mm Hg with a pulse of 126 beats per minute. While you wait for lab work to come back, you order intravenous hydration. After 2 hours, the patient is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%. She continues to have heavy bleeding. Which of the following is the best next step in the management of this patient?

• Perform a dilation and curettage.
• Administer a blood transfusion to treat her severe anemia.
  
• Send her home with a prescription for iron therapy.
• Administer high-dose estrogen therapy.
• Administer antiprostaglandins.
  

The administration of high-dose estrogen therapy is the preferred way to manage this patient. In women who have suffered heavy and acute bleeding attributed to anovulation, 25 mg of conjugated estrogen can be administered every 4 hours until the bleeding abates. The estrogen will help stop the bleeding by building up the endometrium and stimulating clotting at the capillary level. Since the bleeding is heavy and acute, a D&C will not help stop the bleeding, because the lining is already thinned and atrophic. In older women, a D&C might be helpful in obtaining tissue for pathology to rule out endometrial cancer. In this young patient who is resuscitated and stabilized with intravenous fluids, there is no indication for a blood transfusion as long as the bleeding abates. Iron therapy alone would not be adequate for this patient; the bleeding must be stopped first. Antiprostaglandins have no role in curtailing hemorrhage in a woman suffering from anovulation. They have been used with some success in ovulatory women who have heavy cycles or in women with menorrhagia caused by use of the intrauterine device. It is thought that prostaglandin synthetase inhibitors reduce the amount of bleeding by promoting vasoconstriction and platelet aggregation. The administration of high-dose estrogen therapy is the preferred way to manage this patient. In women who have suffered heavy and acute bleeding attributed to anovulation, 25 mg of conjugated estrogen can be administered every 4 hours until the bleeding abates. The estrogen will help stop the bleeding by building up the endometrium and stimulating clotting at the capillary level. Since the bleeding is heavy and acute, a D&C will not help stop the bleeding, because the lining is already thinned and atrophic. In older women, a D&C might be helpful in obtaining tissue for pathology to rule out endometrial cancer. In this young patient who is resuscitated and stabilized with intravenous fluids, there is no indication for a blood transfusion as long as the bleeding abates. Iron therapy alone would not be adequate for this patient; the bleeding must be stopped first. Antiprostaglandins have no role in curtailing hemorrhage in a woman suffering from anovulation. They have been used with some success in ovulatory women who have heavy cycles or in women with menorrhagia caused by use of the intrauterine device. It is thought that prostaglandin synthetase inhibitors reduce the amount of bleeding by promoting vasoconstriction and platelet aggregation.

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