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transfusion. Control of the bleeding is usually accomplished with hormonal
treatment, commonly using a combined estrogen and progestin approach ( Table
92.5 ). Estrogen is used to stop the bleeding, by causing vasospasm of the spiral
arteries, and support the endometrium. A progesterone agent must be
administered simultaneously or soon after the administration of estrogen to
produce a more stabilized secretory endometrium. Any of the OCPs with 0.03 to
0.05 mg of ethinyl estradiol and a progestin provides a convenient means of
administering the two hormones together. Commonly used pills include ethinyl
estradiol 0.03 mg/norgestrel 0.3 mg or ethinyl estradiol 0.05 mg/norgestrel 0.5
mg. For brisk bleeding, one tablet may be given up to four times a day until the
bleeding stops. The medication may then be gradually tapered as long as the
bleeding remains ceased (e.g., one tablet three times a day for 3 days, then one
tablet two times a day for 2 days, then one tablet a day to complete the active pills
in the pack). Note that recurrence of bleeding is common during the pill taper, but
is generally much less than the initial bleeding that led to the clinical presentation.
Although commonly used, there is limited scientific evidence supporting the
efficacy of various pill taper protocols and a variety of approaches have been
published. Obstetrician-gynecologists commonly report tapers with 4-3-2-1 OCP
tablets prescribed for consecutive days or 3-3-2-2-1 OCT tablets prescribed for
consecutive days. A European Consensus group offered four oral options for
hormonal treatment of acute bleeding in women without underlying bleeding
disorders:
1. birth control pills with either 30 mcg or 50 mcg of ethinyl estradiol (EE) in
combination with any progestin to be taken every 6 hours until bleeding
stops (with a reevaluation at 48 hours);
2. norethindrone acetate 5 mg to 10 mg every 4 hours; or
3. MPA 10 mg every 4 hours (up to 80 mg/day).
Patients should be instructed to continue the pill taper even if bleeding
resumes. Having the patient increase the hormone dose again is likely to result in
a recurrence of bleeding once tapering begins again. Nausea is a common side
effect of estrogen and can be treated symptomatically with prophylactic

antiemetics. If the emergency physician is discharging the patient home, provide
three prescriptions to the patient. The first prescription is for the above taper
regimen with instructions to skip the placebo week in the pill pack. The second
prescription is for a second hormonal pill pack with instructions to take one tablet
daily after finishing the taper. The third prescription should be for an antiemetic
to use during the first 5 days of the taper when high-dose estrogen is being
ingested. The diagnoses should be included on the prescriptions, as many