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Pre & Post Menopausal Vaginal Bleeding

Megan Jones, MD and Neda Frayha, MD
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Neda sits down with Megan Jones, high risk OB/GYN who you’ve heard on our shows before. She’s a fantastic educator and breaks down the algorithmic approach for the pre vs. post menopausal vaginal bleeding to know what to do in the urgent phase versus what can be worked up by Gynecology. 

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Pamela K., DNP -

One type of patient you didn't discuss is the patient with severe bleeding. Obviously from urgent care, pt goes to ED, but what about managing them while they are still in UC. What do you recommend for packing? Thank you.

Mike W., MD -

From Megan:
In an urgent care setting, I'd pack the vagina with kerlix.
Depending on how stable the patient is, EMS with IVF and a quick trip to a hospital for IV estrogen/blood products is preferred.
If stable, then referring to a hospital for further evaluation and consultation with OBGYN is appropriate. The more stable heavy bleeders can benefit from TID dosing of an OCP (higher estrogen content like 30-35mcg per pill).
Hope this helps! Let me know if there are any further questions.
Megan

Mizuho M., DO -

Hi Pamela, This is a great question! Mike and I will address this in the MARCH Mailbag outro. Yes Kerlix rolls for packing... don't recommend Foley or Bakri Balloon tamponade in the UC setting. We will also mention IV TXA, but honestly these should be packed and immediately 911 transfered out with a call to recieving doc about how hemodynamically unstable they are and to give GYN a heads up prior to arrival. Mass transfusion protocol, TXA and ED resuscitation are about the limitations of the ED too...most all of these patients who are hemorrhaging this heavily need the OR STAT. Good question! ~Miz

A H. -

What do we do for non-emergent, but urgent bleeding (say hgb dropped over 2 week period from (11 to 8)) whereby, the patient has had thrombotic disease, or CVA, or breast or GU cancer, or liver disease?

Mizuho M., DO -

Good question...you can do a few things: 1) Start Iron supplements 2) Refer to GYN (esp if over 40, as they need an endometrial biopsy 3) if heavy active bleeding ok to start medroxyprogesterone (provera 10 mg x 10 days) until they can be seen by GYN. This wont alter their EMB nor will it increase risk of thromboembolism. You can safely give this to both pre/post menopausal women. Ultimately pre-menopausal women would benefit most from IUD (mirena) but we obviously dont insert these in the acute care setting...hence GYN for IUD consideration which is now ACOG's #1 recommendation. But until they get there provera x 10 days and return precautions. Thanks for the question AH! ~Miz

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Urgent Care RAP November 2019 Written Summary 2 MB - PDF

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