Substance use disorder: contraceptive options counseling

What’s New in Contraception?

Contraceptive Technology Conference!

Biologic sexism of STIs

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding


Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm


Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception New and Improved

Acute Excessive Uterine Bleeding: New Management Strategies
January 2014


Heavy and prolonged bleeding on a chronic basis causes significant health problems (resulting from severe anemia) and quality of life issues. With the FDA approval of the Levonorgestrel IUS20, tranexamic acid (antifibrinolytic agent), and the estradiol valerate/dienogestrol oral contraceptive as treatments for women with that problem, clinicians have many important options to offer. The clinical trials for each of these agents have been rigorous and provide excellent data from hundreds of women about the safety and efficacy of these treatment options.1, 2, 3, 4, 5, 6 In addition, comparative trials, especially comparing the LNG-IUS with surgical treatments such as endometrial ablation and hysterectomy, have demonstrated even more richly how effective these options are in women with differing underlying pathologies accounting for their excessive bleeding.7, 8, 9 There are also off-label uses of NSAIDs, other combined hormonal contraceptives used cyclically or continuously, as well as DMPA to help women reduce their monthly blood loss.10, 11

There are no FDA approved products for treatment of acute excessive bleeding and, amazingly, the clinical evidence supporting any of the medical therapies commonly used to control acute bleeding is embarrassingly scant. Textbooks abound with suggested treatments.12, 13 Many hypotheses have been advanced about the effects needed from a therapy to arrest bleeding. However, these are based on only a handful of very small prospective clinical studies in the literature.14, 15, 16

The classic study done by Devore, et al., involved only 17 subjects given high-dose intravenous conjugated equine estrogen and another 17 controls given placebo infusions over a 5-hour study period in an ER setting.17 At 3 hours, the placebo had a better response than the CEE treatment, but at 5 hours the results reversed. The thought was that the woman’s bleeding was coming from her denuded epithelium. Estrogen was thought to induce endometrial proliferation to cover the denuded patch and also to help cause/stabilize intravascular clotting in the uterine vessels. Progestin was added later to stabilize the remaining un-shed endometrium. Withdrawal of the hormones at a later date would induce a coordinated and limited bleeding episode. The other 2 studies were small scale studies (9 patients each), but reinforced DeVore’s findings.18, 19 In this paradigm, administering progestin would only slow the repair process by down-regulating estrogen receptors in the endometrium.

The physiology must be much more complex because high-dose progestins administered to 24 hospitalized adolescents was very effective as a single therapy.20

In 2006 Munro, et al., reported the first randomized, prospective one-month trial of estrogen-containing oral contraceptives and high-dose MPA (see Table 1 for the doses used). Despite a long recruitment time and ample numbers of potential subjects, only 40 women were enrolled into the study because clinicians each had their own favorite treatment and/or were loath to randomize their patients. However, the study showed that both treatments were very effective. None of the subjects required surgery. Most women were satisfied or very satisfied with their therapy (see Table 2 for outcomes). Given that MPA is relatively inexpensive and carries none of the risks of venous thromboembolism associated with high-dose estrogen, it is a very welcome addition to our therapeutic armamentarium and is our first-line treatment today.

One other option that has been studied in a single-arm prospective study involving 48 women (the largest number of subjects yet) used MPA 20 mg orally 3 times a day for 3 days combined with DMPA 150 mg intramuscularly.21 In this study, all women stopped bleeding by 5 days. In fact, over 25% stopped in 24 hours and the mean number of pads used in first 24 hours by those who did not completely stop bleeding was 2, down from 8 pads. Long-term follow-up was not done prospectively in this study, but none of the women who were not lost to follow-up required any surgery during the 3-month treatment. We are starting a comparative trial for in patients soon and should be able to report on more detail about bleeding patterns in the weeks and months following the DMPA injection.

The American College of Obstetricians and Gynecologists has recently published Committee Opinion Number 557, which emphasizes the role of estrogen-based therapies, but mentions Munro’s progestin-only regimen.22

Look below for the current protocol followed by the Women’s Health Care Clinic at Harbor-UCLA Medical Center for the treatment of acute excessive bleeding. Please feel free to adopt or adapt it to your practice. Read Acute and or Chronic Heavy and or Prolonged Menstrual Bleeding for a detailed protocol.


Table 1: Treatment Regimens

COC Regimen
-35 mg/EE/1.0 mg norethindrone acetate, one tablet orally 3 times a day for 7 days, then 
-20 mcg EE/1.0 mg norethindrone acetate, one tablet orally once daily for 21 days
MPA Regimen
-10 mg medroxyprogesterone acetate (MPA), 2 tablets orally, 3 times a day for 7 days, then
-10 mg MPA, 2 tablets orally once daily for 21 days


Table 2: Outcomes from Munro’s Study Groups      

Surgery needed 9% 5%
Cessation of bleeding, % in 2 weeks 76% 88%
Days to cessation 3 3

Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding. Obstet Gynecol 2006;108:924-9



  1.  Jensen J, Mansour D, Lukkari-Lax E, et al. Bleeding patterns with the levonorgestrel-releasing intrauterine system when used for heavy menstrual bleeding in women without structural pelvic pathology: a pooled analysis of randomized controlled studies. Contraception. 2013;87(1):107-12.
  2. Kaunitz AM, Bissonnette F, Monteiro I, et al. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(3):625-32.
  3. Leminen H, Hurskainen R. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health. 2012;4:413-21.
  4. Freeman EW, Lukes A, VanDrie D, et al. A dose-response study of a novel, oral tranexamic formulation for heavy menstrual bleeding. Am J Obstet Gynecol. 2011;205(4):319.e1-7.
  5. Jensen JT, Parke S, Mellinger U, et al. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777-87.
  6. Fraser IS, Parke S, Mellinger U, et al. Effective treatment of heavy and/or prolonged menstrual bleeding without organic cause: pooled analysis of two multinational, randomised, double-blind, placebo-controlled trials of oestradiol valerate and dienogest. Eur J Contracept Reprod Health Care. 2011;16(4):258-69.
  7. Silva-Filho AL, Pereira Fde A, de Souza SS, et al. Five-year follow-up of levonorgestrel-releasing intrauterine system versus thermal balloon ablation for the treatment of heavy menstrual bleeding: a randomized controlled trial. Contraception. 2013;87(4):409-15.
  8. de Souza SS, Camargos AF, de Rezende CP, et al. A randomized prospective trial comparing the levonorgestrel-releasing intrauterine system with thermal balloon ablation for the treatment of heavy menstrual bleeding. Contraception. 2010;81(3):226-31.
  9. Middleton LJ, Champaneria R, Daniels JP, et al. Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients. BMJ. 2010;341:c3929.
  10. Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;1:CD000400.
  11. Farquhar C, Brown J. Oral contraceptive pill for heavy menstrual bleeding. Cochrane Database Syst Rev. 2009;(4):CD000154.
  12. Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and Infertility. 7th Edition. Philadelphia, PA. Lippincott Williams & Wilkins. 2004.
  13. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. 8th Edition. Philadelphia, PA. Lippincott Williams & Wilkins. 2010.
  14. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding–a double-blind randomized control study. Obstet Gynecol. 1982;59(3):285-91.
  15. Rao KP. Treatment of menstrual disorders with a combination of norgestrel and ethynyl estradiol. Curr Med Pract. 1971;15(1):586-9.
  16. Foss GL. A clinical trial of a new totally synthetic low dose progestagen. J Reprod Fertil. 1969;18(1):59-66.
  17. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding–a double-blind randomized control study. Obstet Gynecol. 1982;59(3):285-91.
  18. Foss GL. A clinical trial of a new totally synthetic low dose progestagen. J Reprod Fertil. 1969;18(1):59-66.
  19. Rao KP. Treatment of menstrual disorders with a combination of norgestrel and ethynyl estradiol. Curr Med Pract. 1971;15(1):586-9.
  20. Aksu F, Madazli R, Budak E, Cepni L, Benian A. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust N Z J Obstet Gynaecol. 1997;37(2):228-231.
  21. Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013;208(6):499.e1-5.
  22. American College of Obstetricians and Gynecologists. ACOG Committee Opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891-6.


Anita Nelson, MD, professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA, and medical director of the Women’s Health Care Programs, Harbor-UCLA Medical Center