Suggested Combined OCP Regimens for Abnormal Bleeding
| Use a monophasic OCP such as: |
| • Norgestrel 0.3 mg/ethinyl estradiol 30 μg (Lo/Ovral, Low-Ogestrel, Cryselle).a |
| • Levonorgestrel 0.15 mg/ethinyl estradiol 30 μg (Nordette, Levlen, Levora, Portia).a |
| For all patients: |
| • Advise the patient to keep a menstrual calendar. |
| • Ensure iron stores are addressed. Patients typically need several months of oral iron supplementation to replete iron stores, and then should be instructed in maintenance of iron needs. |
| • If OCPs are used for treatment and then discontinued, consider cyclic progestin therapy to prevent recurrences. |
| A. For mild bleeding—menses slightly prolonged or cycle slightly more frequent, without anemia (Hgb normal): |
| • May be observed for several cycles and provided treatment with iron and NSAIDs such as ibuprofen or naproxen sodium. |
| • Consider treatment with OCP or progestin. |
| • If choose to treat with OCP: 1 pill daily for 21 d, followed by 1 wk of placebo pills or 1 hormone pill continuously for 84-day cycles or longer. |
| • Continue this regimen for 3–6 mo.b |
| B. For moderate bleeding—menses lasting >7 d or cycle frequency <3 wk and mild anemia (Hgb 10–11 g/dL): |
| • If the patient is not bleeding significantly at the time of the visit, is not already on hormonal therapy, and anemia is mild: 1 pill a day for 21 d is a reasonable first step. |
| • If patient is bleeding moderately at time of visit: 1 pill twice a day until bleeding stops, followed by 1 hormonal pill a day for at least 21 d is a reasonable first step. |
| • If bleeding is under control, continue cyclic 21 day or may elect extended cycles for 3–6 mo.b |
| • Follow serial Hgbs, as needed; if bleeding persists, may need to continue twice-daily pill for a short interval. |
| C. For severe bleeding with moderate anemia (Hgb 8–10 g/dL) |
| • Consider inpatient admission unless patient’s bleeding is slowing and family is reliable, has transportation, and is reachable by phone. |
| • For severe bleeding: 1 pill four times a day for 2–4 d, with antiemetic as needed 2 h before each pill; followed by 1 pill three times a day for 3 d; and then 1 pill twice a day for at least 2 wk. (For this regimen, prescribing OCPs “four times a day” should be written as “1 pill every 6 hours” and “3 times a day” as “1 pill every 8 hours” in order to maintain hormonal concentrations.) |
| • For bleeding that is slowing and Hgb >9 g/dL: 1 pill twice a day can be initiated as a first step. |
| • Follow closely with serial Hgb; if anemia or bleeding persists, may need to continue twice-daily hormonal pill and eliminate pill-free interval until Hgb has returned to normal. |
| • Once Hgb has normalized, cycle using 21 once-daily pills and 5–7 d of placebo or extended cycles for 6 mo.b |
| D. Severe bleeding with severe anemia (Hgb ≤7 g/dL, orthostatic vital signs): |
| • Admit for inpatient management. Transfusion needs are individualized on the basis of Hgb, orthostatic symptoms, amount of ongoing bleeding, and the ability to gain control of the bleeding. |
| • Most patients can be treated with OCPs: 1 pill every 4–6 h until bleeding slows (usually takes 24–36 h), with antiemetics as needed; 1 pill four times a day for 2–4 d; 1 pill three times a day for 3 d; 1 pill twice a day until hematocrit is >30%. |
| • Occasionally intravenous conjugated estrogens (Premarin) 25 mg every 4 h for 2–3 doses are used in severe acute hemorrhage. It is very important to remember that the estrogen will stop the bleeding but if a progestin is not added, a re-bleed from estrogen withdrawal will occur when the IV estrogen is discontinued. |
| • Consider antifibrinolytic therapy. |
| • Once Hgb has normalized, cycle using 21 once-daily pills and 5–7 d of placebo or use extended cycles for 6–12 mo.b |
Reprinted with permission from Gray SH, Emans SJ. Abnormal vaginal bleeding in the adolescent. In: Emans SJ, Laufer MR, eds. Emans, Laufer, and Goldstein’s Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011:159–167. Hgb=hemoglobin.
↵a Mention of brand name does not imply endorsement of a particular product.
↵b It is important to reconsider a patient’s need for birth control before discontinuing OCP therapy.