An 18-year-old woman comes to the emergency department with heavy vaginal bleeding for the past 3 days. The patient has soaked 6 thick sanitary pads today and has had several large blood clots. She has bled through her clothing for the past 2 nights. The patient has no syncope, palpitations, or dyspnea on exertion. There is no history of recurrent epistaxis, easy bleeding, or bruising. Menarche was at age 14; her menstrual periods have been irregular since the onset of menses. She has never been sexually active. The patient has no chronic medical conditions and has had no surgeries. Family history is noncontributory. She has no known drug allergies. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 95/min. BMI is 28 kg/m². Mucous membranes are moist and capillary refill is normal. Cardiac examination shows a normal rate and regular rhythm. Pelvic examination reveals bleeding from the cervix after several large clots are evacuated from the vaginal vault. On bimanual examination, the uterus is small and mobile; there are no adnexal masses. Urine pregnancy test is negative. Pelvic ultrasound shows a small uterus with a thickened endometrium and normal ovaries bilaterally. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bede_426b_8f63_01499fab0e44_MD0005_00 Anovulation is common during the first few years of menarche and can cause irregular, heavy menstrual periods. In the absence of ovulation, menstrual cycles lack their regular periodicity. The endometrium builds up under the influence of estrogen; however, without the influence of progesterone, the cue to slough the endometrium is lacking and menstrual-like bleeding occurs due to estrogen breakthrough bleeding. Therefore, patients often present with prolonged vaginal bleeding with passage of blood clots; initial evaluation includes assessing hemodynamic stability and estimating the volume of blood loss. absence of ovulation Treatment of an acute, heavy bleeding episode in hemodynamically stable patients (eg, mild anemia, no coagulation abnormalities) involves endometrial stabilization via hormonal therapy. Estrogen promotes hemostasis through further proliferation of the disordered endometrium and repairing the bleeding sites. First-line treatment is with combination oral contraceptives with high-dose estrogen. Intravenous conjugated estrogen is used in patients who either cannot tolerate oral medications or continue to bleed despite oral therapy (Choice A). (Choice B) In a dilation and curettage, the endometrium is surgically removed to stop acute bleeding in hemodynamically unstable patients whose bleeding has not improved with intravenous estrogen or have contraindications to medical management (eg, thromboembolism). This patient is hemodynamically stable and has no contraindications to estrogen therapy. (Choice C) An endometrial ablation is used to treat heavy, ovulatory menses in premenopausal women by destroying and removing the endometrium. This procedure is contraindicated in patients who desire future fertility, as endometrial ablation is associated with multiple obstetric complications (eg, placenta accreta, premature birth, perinatal mortality). (Choice D) Progestin-containing implants are used for contraception. They are not indicated in the management of an acute bleeding episode due to the slow onset of action and irregular bleeding associated with initial use. Educational objective: The treatment of acute uterine bleeding is combination oral contraceptives containing high-dose estrogen, which stabilizes the endometrium and stops the bleeding. References: Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. (http://www.ncbi.nlm.nih.gov/pubmed/22946701)

An 18-Year-Old Woman Comes to the Emergency Department with Heavy