Abnormal Uterine Bleeding and COVID-19 – April 2020 guidance
FIGO MDC SARS-CoV-2 Response
Advice for Healthcare Providers
Nonpregnant Women in the Reproductive Years with Abnormal Uterine Bleeding
- During this time, visits to health care providers (HCPs), clinics and hospitals should be minimized to preserve resources for the pandemic and to limit dissemination of this coronavirus (SARS-CoV-2) and spread of COVID-19 disease.
- There is no reason to think that this SARS-CoV-2 has any impact on abnormal uterine bleeding (AUB) of any type including the symptoms of heavy and/or irregular menstrual bleeding.
- All women, but especially those with the symptom of heavy menstrual bleeding (HMB) are at risk for iron deficiency and iron deficiency anemia and should ensure at the very least that dietary iron intake is adequate and supplemented with oral iron if appropriate. To minimize nausea and, perhaps increase absorption alternate day dosing of 60-130 mg of elemental iron may be the most useful.
- Those with acute HMB with passage of clots should contact an appropriate HCP urgently for instructions.
- Those with the recurrent symptom of cyclic (q 24-38 days) HMB. This would include FIGO System 2 (PALM-COEIN) causes such as AUB-A, Lsm, -C and -E that could potentially be alleviated (unless there are contraindications) by the use of appropriate doses of tranexamic acid or multidose progestins such as continuous medroxyprogesterone acetate, preferably under remote guidance from an appropriate HCP.
- Tranexamic acid dosing is typically limited to five days during menses at orally administered typical doses of up to 1,300 mg three times day in the US and up to 1 gram four times per day in other countries(1).
- Cyclical progestin therapy, administered in what is presumed to be the luteal phase, is generally ineffective but “long cycle” oral progestins taken for 3-4 weeks of each month (or, presumably, continuously) can be effective(2).
- Published regimens include norethisterone (norethindrone) 5 mg three times per day from day 5 to day 26 of the cycle or medroxyprogesterone acetate (MPA) 10-20 mg per day for 21 days each calendar month(2).
- There is evidence that norethindrone (and norethindrone acetate) is converted to ethinyl estradiol – approximately 0.2-0.4% - a circumstance that might make it less suitable than MPA for those at enhanced risk for venous thromboembolic disease or other contraindications to systemic estrogen use given that the suggested doses would result in serum ethinyl estradiol levels equivalent to those of low to moderate dose combined estrogen and progestin oral contraceptives(3).
- Individuals with irregular uterine bleeding likely have AUB-O due to declining ovarian function, but, especially in the later reproductive years, and in those with other risk factors such as obesity, there is increased chance of endometrial cancer. Such individuals should contact their doctor for instructions in case further investigation is required.
Since the advice posted had to be rapidly prepared due to the challenging times it was not subject systematic review of the evidence or peer review of the documents.
- Bryant-Smith AC, Lethaby A, Farquhar C, Hickey M. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018;4:CD000249.
- Bofill Rodriguez M, Lethaby A, Low C, Cameron IT. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;8:CD001016.
- Chu MC, Zhang X, Gentzschein E, Stanczyk FZ, Lobo RA. Formation of ethinyl estradiol in women during treatment with norethindrone acetate. The Journal of Clinical Endocrinology and Metabolism. 2007;92(6):2205-7.
See also: https://mk0britishsociep8d9m.kinstacdn.com/wp-content/uploads/2020/03/Joint-RCOG-BSGE-BGCS-guidance-for-management-of-abnormal-uterine-bleeding-AUB-in-the-evolving-Coronavirus-COVID-19-pandemic-300320-2.pdf for advice from the RCOG- British Society for Gynaecological Endoscopy-British Society of Gynaecological Cancer.