Menorrhagia: CHAM ED PROTOCOL

Last updated 12/2013

Obtain CBC, bHCG, and orthostatic vital signs Before Consulting Adolescent Medicine Fellow
(office: 718-920-2180 or page on-call fellow)

Mild Anemia – Hb > 11 g/dL

• Reassurance

• Daily multivitamin with iron

• ED Discharge Guidance:

  • Keep menstrual calendar.

  • Follow up with PCP in 1 week.

  • Routine referral to Adolescent Medicine (718- 741-2450.)

Moderate Anemia – Hb > 9-11 g/dL without profuse bleeding (soaked pad every 3-4 hours)

• Consult Adolescent Medicine Fellow

• If no estrogen contraindications:

  • Monophasic combined oral contraceptive pill containing 35 mcg of ethinyl estradiol i.e. Orthocyclen (Sprintec) or Ortho-novum 1/35.

  • Give the first dose in ED. Then, take OCP 1 pill BID until follow up with Adolescent Medicine within 1 week.

  • On OCP Rx must indicate “for menorraghia, discard placebo pills, dispense 2 packs”

• If estrogen contraindications*:

  • Medroxyprogesterone acetate (Provera) 10 mg PO daily until follow up with Adolescent Medicine within 1 week First dose in ED.

• ED Discharge Guidance:

  • For anemia: Ferrous Gluconate 325 mg BID (better tolerated formulation) with Colace 100 mg BID.

  • Ensure patient has Adolescent Medicine office contact information (718-920-2180).

  • If bleeding does not stop or significantly slow down in 2 days, they MUST contact Adolescent Medicine.

Severe Anemia – Hb < 9 g/dL OR Profuse bleeding with orthostasis (even if Hb >9)

• Type and Cross; consider fluid resuscitation and pRBCs

• Consult Adolescent Medicine Fellow

• If no estrogen contraindications:

  • Monophasic combined oral contraceptive pill QID, First dose STAT.

  • Conjugated IV estrogen (Premarin) 25 mg q4 hours x 4 doses max, rarely need more than 2 doses). First dose STAT.

  • Only use Premarin IF profuse bleeding present on physical exam.

• If estrogen contraindications*:

  • Medroxyprotesterone acetate (Provera) 10 mg PO and Tranexamic acid 1300mg PO q8 hours, First dose STAT.

• IF bleeding disorder (e.g. thrombocytopenia) in addition to Adolescent Medicine, consult Hematology/Oncology

• ADMIT TO CHAM 6 (even if patient < 13 years old)

bHCG positive OR Flooding (soaked pad in < 1 hour) with unstable vitals

• Consult Gynecology for Obstetric emergency or Suspicion of high vaginal laceration.

• May need STAT exam under anesthesia for diagnosis and repair

• May give Conjugated IV estrogen (Premarin) 25mg q4 hours and Tranexamic acid 1300 mg PO q8 hours. First doses STAT.

Additional laboratory testing to consider in consultation with Adolescent Medicine fellow:

TSH, FT4, prolactin, LH, FSH, free & total testosterone, androstenedione, DHEA-S, sex hormone binding globulin, von Willebrand panel, PT/PTT If sexually active: screen for HIV, Gonorrhea and Chlamydia

*Estrogen Contraindications In Adolescents:

• Migraine with aura

• Untreated Hypertension

• Known clotting risk (e.g. APL Antibody)

• Untreated hyperlipidemia

• CVD/stroke/DVT history

• Liver disease, Pregnancy

• Breast cancer