In the past I have had one plan for treating dysfunctional uterine bleeding (DUB)—Provera (Medroxypro-
gesterone acetate) 10mg daily for 10 days (ACOG recommends 20mg/day for 7days), coupled with the following speech, “I am going to give you a medication that will help with your bleeding, but you can only take if for 10 days. At the end of those 10 days if you don’t transition to another hormonal medication the bleeding will come back and will probably be worse. So you need to get into your PCP or OBGYN in the next 4-5 days to get a prescription for another medication.”  Needless to say, there are a number of holes in the logic of that speech.

(While Provera can be used as a long term medication option—it is used in 10-14 day cycles and withdrawal bleeding is an expected part of the cycle.)

Recently another ray of DUB hope drifted down from combined wisdom of the OBGYN residents: Sprintec (norgestimate and ethinyl estradiol), a combined estrogen/progesterone pill. The upside is that Sprintec is a medication that can be continued after the initial loading dose. This allows patients to continue the suppression hormones for a reasonable period of time; making it reasonable to actually get follow-up within our system while the medication is effective, even if they do not have a PCP yet.  The down side—it has estrogen. Estrogen increases the risk for blood clots and cannot be used in smokers over 35 years old, patients with prior clots, migraines with aura or ischemic heart disease.

For dosing Sprintec ACOG suggests  3 pills a day for 7 days and then a single pill a day. There is also support in the OBGYN literature for a 4—>3—>2—>1 regimen (pills per day). This is a simple taper that limits the acute exposure to estrogen.  In the appropriate patients the 4-3-2-1 strategy is the one I am going to start using.

There are a number of causes of of DUB that will need to be evaluated by the OBGYN team. They are broken up into structural problems (Leiomyomas, polyps, adenomyosis, hyperplasia, malignancy) and non-structural problems (ovulatory dysfunction, coagulopathy, iatrogenic causes, endometrial cause). Therefore, ALL PATIENTS WITH ABNORMAL UTERINE BLEEDING NEED FURTHER EVALUATION—which can be a downside of providing a longer course of medication, because one  benefit of a limited supply of hormones is that it pushes the patient to be evaluated so that we do not miss cancer as the cause of the bleeding.

Once the initial bleeding is controlled there are other possible long term treatments including IUD and surgical options for some conditions.

https://www.contemporaryobgyn.net/gynecology/managing-acute-heavy-menstrual-bleeding
UpToDate: Management of Abnormal Uterine Bleeding
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women?IsMobileSet=false