Endometrial sampling
Long-term unopposed estrogen stimulation in anovulatory patients can result in endometrial hyperplasia, which can progress to adenocarcinoma; therefore, in perimenopausal patients who have been anovulatory for an extended interval, the endometrium should be biopsied.
Biopsy is also recommended before initiation of hormonal therapy for women over age 30 and for those over age 20 who have prolonged bleeding.
Hysteroscopy and endometrial biopsy with a Pipelle aspirator should be done on the first day of menstruation (to avoid an unexpected pregnancy) or anytime if bleeding is continuous. Hysterosonography with uterine saline infusion may also be used.
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Treatment
Medical protocols for anovulatory bleeding (dysfunctional uterine bleeding) are similar to those above.
Hormonal therapy Human growth hormone
In women who do not desire immediate fertility, hormonal therapy may be used to treat menorrhagia.
A 21-day package of oral contraceptives, containing 35 mcg of estrogen ( Ortho-Novum 1/30), is used. The patient should take one pill three times a day for 7 days. During the 7 days of therapy, bleeding should subside, and, following treatment, heavy flow will occur. After 7 days off the hormones, another 21-day package is initiated, taking one pill a day for 21 days, then no pills for 7 days.
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Alternatively, medroxyprogesterone ( Provera), 10-20 mg per day for days 16 through 25 of each month, will result in a reduction of menstrual blood loss. Pregnancy will not be prevented.
Patients with severe bleeding may have hypotension and tachycardia. These patients require hospitalization, and estrogen (Premarin) should be administered intravenously as 25 mg every 4-6 hours until bleeding slows (up to a maximum of four doses). Oral contraceptives should be initiated concurrently as described above.
Iron should also be added as ferrous gluconate 325 mg tid.
Surgical treatment can be considered if childbearing is completed and medical management fails to provide relief.
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