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Patients with severe bleeding, hemodynamic instability, and hemoglobin <10
g/dL should be considered for hospital admission. Refill the intravascular space
with isotonic fluids and evaluate whether a blood or iron transfusion may be
needed. For acute, severe hemorrhage, conjugated estrogen (Premarin) 25 mg IV
every 4 hours for 24 hours may be given. Keep in mind, however, that conjugated
estrogen has a higher risk of thromboembolism than the combined oral
contraceptives. A combined estrogen and progestin pill should be administered
after the first 24 to 48 hours after starting conjugated IV estrogen for stabilization
of the endometrium by progestin. Note that when using IV estrogen, bleeding
may not slow until after the first 12 to 24 hours. Patients whose bleeding does not
significantly improve after one to two doses of conjugated estrogen should be
reevaluated for an alternate cause of bleeding (e.g., bleeding diatheses, anatomic
abnormality).
Before starting any estrogen-containing therapy, assess the patient for any
contraindications to estrogen ( Table 92.6 ). Absolute contraindications include a
history of migraine with aura, deep venous thromboembolism or pulmonary
embolism, inherited prothrombotic disorders, systemic lupus erythematosus with
positive or unknown antiphospholipid antibodies, hypertension (SBP >160 mm
Hg or DBP >100 mm Hg), certain heart conditions (ischemic heart disease,
complicated valvular heart disease, peripartum cardiomyopathy), certain liver
conditions (hepatocellular adenoma, liver malignancy, severe cirrhosis),
postpartum <21 days, stroke, current diagnosis of breast cancer, or history of
complicated solid organ transplant. For a full list see the United States Medical
Eligibility
Criteria
for
Contraceptive
Use
at
.
If estrogen is contraindicated or not tolerated, progestin-only regimens may be

used but the resulting hemostasis is less prompt and less predictable.
Medroxyprogesterone and norethindrone acetate are progestin-only pill options
that may be used. Medroxyprogesterone 10 mg or norethindrone acetate 5 to 10
mg may be given orally up to four times a day. A typical taper may begin as four
times a day for 4 days. If the bleeding stops, then the taper may continue as three
times a day for 3 days, and then twice a day for 2 weeks. The patient’s outpatient
provider may continue to taper the progestin pill to one tablet daily and gradually
discontinue the medication. The clinician should keep in mind that norethindrone
at high doses converts peripherally to ethinyl estradiol. Other medication options
that are available—though not typically administered in an ED setting—include
depot medroxyprogesterone, tranexamic acid, and levonorgestrel-releasing