Acute Heavy Menstrual Bleeding is unpredictable and may significantly impact the health, quality of life and productivity of adolescents and women.

Challenges of Acute HMB

Abnormal uterine bleeding (AUB) may be acute or chronic and is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy.1,2 It can be caused by various factors, including hormonal imbalances, fibroids, polyps, and other uterine or systemic conditions.1 The unpredictable nature of AUB can significantly impact the health and daily functioning of adolescents and women of reproductive age, affecting their quality of life and productivity.

The Women's Health research Collaborative (WHrC) aims to establish an education initiative to raise awareness around abnormal uterine bleeding. Our objectives include contributing to the existing body of evidence and promoting the creation of management guidelines and practice models for the diverse range of healthcare practitioners involved in treating this condition.

Acute AUB refers to an episode of heavy uterine bleeding in the reproductive years unrelated to pregnancy, that, in the opinion of the clinician, is of sufficient quantity to require immediate intervention to prevent further blood loss.1 Acute AUB may occur spontaneously or within the context of chronic AUB (abnormal uterine bleeding present for most of the previous 6 months).4

Awareness

Issues

  • The absence of an ICD-10 diagnostic code for Acute AUB/HMB makes it difficult to determine and describe the precise incidence of the problem

  • Currently, there is no FDA-approved solution specifically approved for the management of Acute HMB

  • Acute HMB is often conflated with Chronic AUB, a circumstance that undermines research, education, and the development of products and professional guidelines for diagnosis and therapy. While the American College of Obstetricians and Gynecologists and Kaiser Permanente Southern California have, nevertheless, published guidance for the diagnosis and management of Acute HMB, the approaches are not widely known or followed (1-3)

Burden of Illness

  • Acute HMB can occur in all reproductive age groups, from adolescence to perimenopause (1)
  • While data are difficult to obtain, it has been estimated that as many as 5% of all Emergency Room Visits are due to Acute HMB(4)
  • Bleeding disorders, such as von Willebrand disease, frequently manifest in adolescent Acute HMB requiring hospital admission(2, 5, 6)
  • Many reproductive-aged girls and women presenting with Acute HMB, have underlying Chronic AUB, a circumstance making them particularly vulnerable to preventable interventions including blood transfusion.

Treatment Challenges

  • The absence of FDA-approved treatments specifically labeled for Acute AUB including Acute HMB
  • Intravenous conjugated estrogens (Premarin® Intravenous) were FDA-approved more than 40 years ago for “short-term…treatment of abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology”. The issues surrounding Acute HMB are nowhere to be found in the approval document (7)(8)
  • Treatment for Acute HMB can vary widely among HCPs, leading to inconsistent care and outcomes
  • Some treatments for Acute HMB, such as hormonal therapies, can have significant side effects that may deter women from continuing their use
  • Studies of treatments designed or applied to girls and women with Acute HMB are limited to repurposed drugs and devices. These include oral progestin regimens, with, or without an estrogen(9), oral followed by intramuscular progestins(10), and the use of intrauterine tamponade with the Foley balloon catheter designed for the urinary bladder (11)
  • In severe cases, surgical interventions like hysterectomy may be required, which can have long-term physical and emotional impacts

Available Treatment Guidance

Despite the paucity of available evidence and lack of FDA-approved interventions, it is important to understand the clinical approach to care and the spectrum of medical and procedural interventions potentially available.

References

1ACOG. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstetrics and gynecology. 2013;121(4):891-6.

2Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019;134(3):e71-e83.

3Munro MG, Southern California Permanente Medical Group's Abnormal Uterine Bleeding Working G. Acute uterine bleeding unrelated to pregnancy: a Southern California Permanente Medical Group practice guideline. Perm J. 2013;17(3):43-56.

4Abbas T, Husain A. Emergency department management of abnormal uterine bleeding in the nonpregnant patient. Emerg Med Pract. 2021;23(8):1-20.

5Claessens EA, Cowell CA. Acute adolescent menorrhagia. American journal of obstetrics and gynecology. 1981;139(3):277-80.

6Smith YR, Quint EH, Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc Gynecol. 1998;11(1):13-5.
7DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding--a double-blind randomized control study. Obstet Gynecol. 1982;59(3):285-91.

8FDA. Premarin Intravenous (conjugated estrogens). Washington DC: FDA; 2006.

9Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006;108(4):924-9.

10Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013;208(6):499 e1-5.

11Goldrath MH. Uterine tamponade for the control of acute uterine bleeding. Am J Obstet Gynecol. 1983;147(8):869-72.

12ACOG. Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019;134(3):e71-e83.
 

Acute HMB Steering Committee

Malcom G. Munro, MD, FRCSC, FACOG   
Chair, FIGO Menstrual Disorders Committee | Co-Chair, SEUD Abnormal Uterine Bleeding Task Force | Voluntary Clinical Professor, David Geffen School of Medicine, UCLA

Sarah O’Brien, MD

Ohio State University

Pamela Dyne, MD

Professor of Clinical Emergency Medicine, David Geffen School of Medicine, UCLA (former Emergency Medicine Program Director and DIO) | Certified Chief Wellness Officer and Director of Coaching, David Geffen School of Medicine, UCLA

Anita Nelson, MD

Professor of Obstetrics and Gynecology Western University Health Sciences and Professor Emeritus of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA