what do you give for DUB?

[dotcb]

Just wondering what other people's practice is.

For a NL healthy, non-pregnant female of childbearing age with excessive heavy +/- irregular uterine bleeding - what do you give?

For a long time I was told to do nothing. NL HCT, NL VS, NL exam, tell them just to F/U, given lack of f/u with us, and thrombosis risks of prescribing hormonal Rx w/o F/U.

Lately, I think I've changed my mind. Need to do better and give something to help. I was speaking to an Ob/Gyn MD yesterday and her answer was - you need to determine what their fertility goals are.

ideally, place them on any 28 day OCP - whatever's cheapest - there seem to be about 50 different brands of these, and she said it really doesn't matter - just look at formulary and insurance and put them on whatever's covered

for really heavy bleeding, and maybe for a woman who wants to become pregnant - norethindrone 10mg x 5-10 days

so I was thinking about prescribing 5-10 days of norethindrone to most women, and suggesting I give them a prescription for the pill, if they're open to having their fertility turned off for awhile.

Just wondering to hear other people's practice patterns or comments.

Thanks

---

Members don't see this ad.

 

[The White Coat Investor]

1 month orthocyclen

 

[Birdstrike]

It depends how much you like playing amateur gyno. You can A, do nothing and refer, or, B, start the birth control pill of your choice (depending on which drug company you own stock in) JK, or, C, start a 7 day course of a progestin, ie, aygestin, and refer. Enjoy.

 

[deleted6669]

1 month orthocyclen

our ob's like this rx as well but they do 2 tabs/day for 1 week(or less if bleeding stops sooner) then go to 1 tab/day thereafter

 

[EM_Rebuilder]

Had this patient recently; was at an OSH and called her Gyn. He had me put her on this medication: http://www.lysteda.com/

I had never heard of it; usually do not like writing stuff I know zip about but less concerned when the patients personal doctor suggests it.

Still need to learn about it; still probably would not give it without Gyn suggestion and FU.

 

[Rendar5]

Had this patient recently; was at an OSH and called her Gyn. He had me put her on this medication: http://www.lysteda.com/

I had never heard of it; usually do not like writing stuff I know zip about but less concerned when the patients personal doctor suggests it.

Still need to learn about it; still probably would not give it without Gyn suggestion and FU.

That's an old med totally redone. It's getting some press in the trauma literature because it is extremely cheap and may reduce bleeding in general.

 

[fuegofrio17]

I was always taught not to treat DUB and refer to GYN for deterimination of the true etiology of bleeding. Hormones, although most frequently improve the condition, can sometimes be deleterious. In a patient with a neuroendocrine neoplasm, hormone treatment can potentiate the tumor. Thus, in cases of undifferentiated vaginal bleeding, I conservatively always refer to GYN.

And remember, new onset vaginal bleeding in a female over fify may very well be cancer.

 

[JustADoc]

I give them an alacasa pill.

 

[SoCuteMD]

A gyn followup appointment.

 

[EctopicFetus]

A gyn followup appointment.

Agreed. What if its cancer and the bleeding stops and they dont f/u. No thanks. If they have an established OB/GYN Ill call them and ask. Otherwise if they are out of state or dont have an OB then I give them a name for f/u. Thats my practice and ill stick to it.

 

[ccfccp]

Maybe this wasn't mentioned, but am I the only one who gives these patients NSAIDs (Motrin)? All of them get Gyn referral, but I usually don't start OCPs unless it seems serious (in which case I usually call our Gyn on call to arrange close follow-up...)

 

[pinipig523]

I'm taught to give nsaids and let them know that what they'll need is an OCP at some point. They need to f/up w/ gyne.

This way, they actually go to the f/up appt and not just lollygag to the next ER. Give them a goal.

"Go get your OCP from this clinic.... now. Stop going to ERs. We all do the same thing."

 

[Lumberg]

A tampon and discharge paperwork.

 

[WilcoWorld]

I understand the above posters' concerns, and if getting follow-up is not a problem in your community, then that seems like a reasonable approach. However, if the patient has symptomatic anemia, is not peri or post menopausal and getting follow up may be difficult, then I think starting an OCP out of the ED (after a benign US result) is reasonable. I've seen a number of DUB's come in with a hematocrit well below 30 and syncope. In these patients I'll do an US, start an OCP and arrange GYN follow-up

Yep, we do a lot of non ED work-ups (both outpatient and inpatient) in my shop.

 

[WilcoWorld]

Also, the "alacasa" pill - love it.

 

[Ceez]

I understand the above posters' concerns, and if getting follow-up is not a problem in your community, then that seems like a reasonable approach. However, if the patient has symptomatic anemia, is not peri or post menopausal and getting follow up may be difficult, then I think starting an OCP out of the ED (after a benign US result) is reasonable. I've seen a number of DUB's come in with a hematocrit well below 30 and syncope. In these patients I'll do an US, start an OCP and arrange GYN follow-up

Yep, we do a lot of non ED work-ups (both outpatient and inpatient) in my shop.

U/S doesn't rule out malignancy. and syncope and low crit gets admitted, transfused, and inpt gyn consultation which equals problem solved. i know most of our patients have poor follow up but it's also important that we recognize the limitations of our training

 

[Hamhock]

Also, the "alacasa" pill - love it.

Most disease processes in the ED deserve a STAT dose of 'alacasa'

HH

 

[WilcoWorld]

U/S doesn't rule out malignancy. and syncope and low crit gets admitted, transfused, and inpt gyn consultation which equals problem solved. i know most of our patients have poor follow up but it's also important that we recognize the limitations of our training

Unfortunately, syncope + anemia does not = admission where I work. You are correct that a normal US doesn't rule-out malignancy. I make these decisions in consultation with OB/GYN for precisely that reason.

 

[roja]

gyn referral. analgesia. return precautions.

 

[EM OR BUST]

Unfortunately, syncope + anemia does not = admission where I work.

Wow! Why do they not admit symptomatic anemia? I've always thought this was a slam dunk admission? Anyone else not able to admit this?

 

[deleted6669]

Wow! Why do they not admit symptomatic anemia? I've always thought this was a slam dunk admission? Anyone else not able to admit this?

One of our obs sends asymptomatic(other than bleeding) folks home with H+H's as low as 6/18 if there is a known tendency to heavy menses and they can show a trend. "start them on iron and have them see me next week". obviously if they are syncopal and this low they stay.
when I volunteer in Haiti we only transfuse < 5/15. others we follow closely after starting iron+ multivits and making sure they have adequate calories and nutrition.

 

[crewmaster1]

Wow! Why do they not admit symptomatic anemia? I've always thought this was a slam dunk admission? Anyone else not able to admit this?

observation protocol, couple of units, and out-pt follow-up on Iron if not bleeding like stink. Most of these people didn't become anemic overnight and don't need to be completely fixed overnight. If they are still actively bleeding and are going to rapidly become anemic again, then gyn can see them while they are getting blood in the obs protocol and will likely start a progesterone burst.