Acute Uterine Bleeding Treatment with Medroxyprogesterone Acetate or Birth Control Pills
Acute Uterine Bleeding Treatment with Medroxyprogesterone Acetate or Birth Control Pills
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Synopsis: This trial is limited by sample size but suggests that both regimens may be effective and reasonably well tolerated.
Source: Munro MG, et al. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006;108:924-929.
In a prospective, randomized trial, both norethindrone 1 mg/ethinyl estradiol 35 mg taken three times a day initially as well as medroxyprogesterone acetate 20 mg t.i.d. initially were comparably effective and reasonably well tolerated.
Forty patients who had non-obstetric acute uterine bleeding and were hemodynamically stable were randomized to one of two treatment approaches. One group received medroxyprogesterone acetate (MPA) 20 mg t.i.d. for a week, then 20 mg q.d. for 3 weeks. The other group received an oral contraceptive pill (OC) containing norethindrone 1 mg and 35 µg of ethinyl estradiol t.i.d. for a week, then daily for 3 weeks. Only 1 patient required nonelective surgery during the study. She had a dilation and curettage performed. Among the 7 patients who did not complete the trial, none of them had surgery. Therefore, 39/40 patients successfully avoided surgery during the study period. The median number of days to cessation of bleeding was 3 in both groups. Cessation of bleeding at 2 weeks was seen in 76% and 88% of the MPA and OC groups respectively. Eighty-one percent of the MPA group and 69% of the OC group acknowledged that they would use the treatment again. There was less compliance with OC than MPA, but the overall side effect profiles were similar.
Commentary
We see it all the time. Anyone who practices any amount of office gynecology is regularly faced with the patient with abnormal uterine bleeding that requires hormonal manipulation. In the "old days," dilation and curettage was used more often than now. . .or at least we hope so. It has long been demonstrated that surgical intervention for abnormal bleeding is not the optimal initial approach. Similarly, intravenous hormonal therapy has long been advocated, but hospitalization carries with it financial and other considerations making it less than desirable. Another common treatment that has proven effective is the "pill taper" in which the patient takes a birth control pill q.i.d., then t.i.d., then b.i.d., then q.d.
This study applies lessons learned by the authors from their own experience as well as from their reading. The sample size of the published study is insufficient to prove efficacy of either treatment or equivalency of the 2 treatments. The study does, however, validate what each of you is already doing and encourages you to continue to look for alternative regimens of hormonal treatment for these patients. In those patients without obvious anatomic causes of bleeding, either progestational treatment or combination estrogen/progestin treatment can stop bleeding with a reasonable side effect profile. The additional estrogen in the OC group could well explain the nausea that many patients and clinicians report. The bloating with high-dose progestin can potentially be seen with either treatment.
Whether 20 mg of MPA is the right dose or not is less of a concern than how you approach these patients. Recognizing that these doses may not be optimal in every patient, the authors acknowledge that alternative regimens may be viable in each case. The beauty of this study is that it gives us clinicians "permission" to try various options that can work for patients in our respective practices without feeling constrained to only use what we find in a textbook or a regimen that has been validated by evidence--based medicine. Nothing against evidence-based medicine—it has lots of answers; but in some areas, such as acute bleeding, it hasn't addressed the topic yet.
In a prospective, randomized trial, both norethindrone 1 mg/ethinyl estradiol 35 mg taken three times a day initially as well as medroxyprogesterone acetate 20 mg t.i.d. initially were comparably effective and reasonably well tolerated.Subscribe Now for Access
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