HEMODYNAMICALLY UNSTABLE Patients who are hemodynamically unstable because of bleeding must be resuscitated according to standard protocols. Attempts should be made to localize the source of bleeding. In women with severe, persistent bleeding, immediate D&C is usually indicated. Uterine packing should be avoided, because it increases the risk of infection and may hide ongoing blood loss.
HEMODYNAMICALLY STABLE Medical management should be considered in hemodynamically stable patients provided the diagnosis is clear. If not, the patient should be referred for further investigation and outpatient management. Short-term hormonal manipulation allows the endometrium to stabilize, which in turn will slow or stop acute bleeding.10 If the endometrium is thin on ultrasound examination, estrogen may be used to stimulate growth of the denuded, raw surface of the endometrium. With the regimen outlined in Table. ..98-8, subsequent bleeding may be heavy but should not be prolonged. Oral contraceptives may be used in women who are not pregnant and have no anatomic abnormalities. The progesterone in the OCP decreases the number of available estrogen receptors and, as a result, bleeding may not stop as quickly as when estrogen is used alone. Side effects include nausea and vomiting.10 Two treatment regimens have been developed using a fixed-dosage pill, with 35 pg ethinyl estradiol and 1 mg norethindrone (T.a.ble...9.8-8). In individuals with persistent light bleeding associated with anovulation, progesterone alone can be used to stabilize an immature endometrium. Bleeding occurs 3 to 10 days after discontinuation and may be heavy due to the large amount of tissue being sloughed.
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