Definition: Severe until excessive bleeding within a quite regular cycle, blood loss >80 ml. Severe bleeding is clinically important, particularly if it is combined with menorrhagia. Blood loss and resulting symptoms can be considerable. The reason may be poor contractility of the myometrium and vessels, but a coagulation disorder should also be kept in mind. A coagulation profile should be obtained in this setting and a hematologist consulted if an abnormality is detected.
Otherwise, initial therapy consists of an attempt to promote the contractility of the myometrium and vessels with ergot alkaloids and prostaglandin synthetase inhibitors during the menstruation. A second-line approach consists of an attempt to promote coagulation within the endometrium with tranexamic acid (Cyklokapron) during the time of bleeding. Progestins in the second part of the cycle may be successful as well as an oral contraceptive pill with low dose of estrogen (20μg Ee or even 15μg Ee). Surgical intervention (e.g., curettage) is obsolete, but may be necessary in very rare cases. In case of excessive bleeding, hospitalization may be required to prevent shock, restore blood volume and stop bleeding with high doses of conjugated estrogens intravenously.
Revision date: July 4, 2011
Last revised: by Jorge P. Ribeiro, MD