Management of Acute Abnormal Uterine Bleeding (2013) PDF

The American College of Obstetricians and Gynecologists WOMEN’S HEALTH CARE PHYSICIANS COMMITTEE OPINION Number 557 April 2013 (Reaffirmed 2019) Committee on Gynecologic Practice...

The American College of Obstetricians and Gynecologists WOMEN’S HEALTH CARE PHYSICIANS COMMITTEE OPINION Number 557 April 2013 (Reaffirmed 2019) Committee on Gynecologic Practice This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women ABSTRACT: Initial evaluation of the patient with acute abnormal uterine bleeding should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. After initial assessment and stabi- lization, the etiologies of acute abnormal uterine bleeding should be classified using the PALM–COEIN system. Medical management should be the initial treatment for most patients, if clinically appropriate. Options include intravenous conjugated equine estrogen, multi-dose regimens of combined oral contraceptives or oral progestins, and tranexamic acid. Decisions should be based on the patient’s medical history and contraindications to therapies. Surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management. The choice of surgical manage- ment should be based on the patient’s underlying medical conditions, underlying pathology, and desire for future fertility. Once the acute bleeding episode has been controlled, transitioning the patient to long-term maintenance therapy is recommended. Abnormal uterine bleeding (AUB) may be acute or venous lines should be initiated rapidly as should the chronic and is defined as bleeding from the uterine cor- preparation for blood transfusion and clotting factor pus that is abnormal in regularity, volume, frequency, or replacements. After the initial assessment and stabili- duration and occurs in the absence of pregnancy (1, 2). zation, the next step is to evaluate for the most likely Acute AUB refers to an episode of heavy bleeding that, etiology of acute AUB so that the most appropriate and in the opinion of the clinician, is of sufficient quantity to effective treatment strategy to control the bleeding can require immediate intervention to prevent further blood be chosen. loss (1). Acute AUB may occur spontaneously or within the context of chronic AUB (abnormal uterine bleeding Etiologies of Acute Abnormal Uterine present for most of the previous 6 months). The general Bleeding process for evaluating patients who present with acute The etiologies of acute AUB, which can be multifacto- AUB can be approached in three stages: 1) assessing rap- rial, are the same as the etiologies of chronic AUB. The idly the clinical picture to determine patient acuity, 2) Menstrual Disorders Working Group of the International determining most likely etiology of the bleeding, and 3) Federation of Gynecology and Obstetrics proposed a choosing the most appropriate treatment for the patient. classification system and standardized terminology for the etiologies of the symptoms of AUB, which has been Assessment of the Patient With Acute approved by the International Federation of Gynecology Abnormal Uterine Bleeding and Obstetrics’ executive board and supported by the Initial evaluation of the patient with acute AUB should American College of Obstetricians and Gynecologists include a prompt assessment for signs of hypovolemia (1, 2). With this system, the etiologies of AUB are class- and potential hemodynamic instability. If the patient is ified as “related to uterine structural abnormalities” and hemodynamically unstable or has signs of hypovolemia, “unrelated to uterine structural abnormalities” and cat- intravenous access with a single or two large bore intra- egorized following the acronym PALM–COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatro- Box 1. Clinical Screening for an genic, and Not otherwise classified (Fig. 1). Determining Underlying Disorder of Hemostasis the most likely etiology of acute AUB is essential for in the Patient With Excessive choosing the most appropriate and effective management Menstrual Bleeding ^ for the individual patient and is accomplished by obtain- ing a history, performing a physical examination, and Initial screening for an underlying disorder of hemostasis requesting laboratory and imaging tests, when indicated. in patients with excessive menstrual bleeding should be structured by the medical history. A positive screening History result* comprises the following circumstances: Obtaining a thorough medical history should be guided Heavy menstrual bleeding since menarche by the PALM–COEIN system and focused on details of One of the following conditions: the current bleeding episode; related symptoms; and past —Postpartum hemorrhage menstrual, gynecologic, and medical history; which can, in turn, guide appropriate laboratory and radiologic test- —Surgery-related bleeding ing. Up to 13% of women with heavy menstrual bleeding —Bleeding associated with dental work have some variant of von Willebrand disease and up Two or more of the following conditions: to 20% of women may have an underlying coagulation —Bruising, one to two times per month disorder (2–4). Other coagulation factor deficiencies, —Epistaxis, one to two times per month hemophilia, and platelet function disorders may be associated with AUB in any age group. Using a screen- —Frequent gum bleeding ing tool in Box 1 can assist the clinician in determining —Family history of bleeding symptoms which patients may benefit from laboratory testing for *Patients with a positive screening result should be considered disorders of hemostasis. Additionally, systemic diseases, for further evaluation, including consultation with a hematolo- such as leukemia and liver failure, and medications, such gist and testing for von Willebrand factor and ristocetin cofac- as anticoagulants or chemotherapeutic agents, can impair tor. coagulation and be associated with AUB. Modified from Kouides PA, Conard J, Peyvandi F, Lukes A, Kadir R. Hemostasis and menstruation: appropriate investigation for under- Physical Examination lying disorders of hemostasis in women with excessive menstrual A physical examination of a patient who presents with bleeding. Fertil Steril 2005;84:1345–51. [PubMed] [Full Text] acute AUB should focus on signs of acute blood loss Abnormal uterine bleeding: Heavy menstrual bleeding (AUB/HMB) Intermenstrual bleeding (AUB/IMB) PALM—structural causes: COEIN—nonstructural causes: Polyp (AUB-P) Coagulopathy (AUB-C) Adenomyosis (AUB-A) Ovulatory dysfunction (AUB-O) Leiomyoma (AUB-L) Endometrial (AUB-E) Submucosal leiomyoma (AUB-LSM) Iatrogenic (AUB-I) Other leiomyoma (AUB-LO) Not yet classified (AUB-N) Malignancy and hyperplasia (AUB-M) Fig. 1. Basic PALM–COEIN classification system for the causes of abnormal uterine bleeding in nonpregnant reproduc- tive-aged women. This system, approved by the International Federation of Gynecology and Obstetrics, uses the term “abnormal uterine bleeding” paired with terms that describe associated bleeding patterns (“heavy menstrual bleeding” or “intermenstrual bleeding”), a qualifying letter (or letters) to indicate its etiology (or etiologies), or both. Abbreviation: AUB indicates abnormal uterine bleeding. (Data from Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classifica- tion system [PALM-COEIN] for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13. [PubMed] [Full Text]) ^ 2 Committee Opinion No. 557 (hypovolemia and anemia) and findings that suggest the and women with either abnormalities in initial labora- etiology of the bleeding. The patient should be evaluated tory testing or positive screening results for disorders to determine that she has acute AUB and not bleed- of hemostasis should be considered for specific tests ing from other areas of the genital tract. Thus, a pelvic for von Willebrand disease and other coagulopathies, examination (including a speculum examination and a including von Willebrand–ristocetin cofactor activity, bimanual examination) should be performed to identify von Willebrand factor antigen, and factor VIII (2, 5). any trauma to the genital tract and vaginal or cervical Based on the clinical presentation, a workup for thyroid findings that could cause vaginal bleeding. The pelvic disorders, liver disorder, sepsis, or leukemia may be indi- examination also will determine the amount and inten- cated. Endometrial tissue sampling should be performed sity of bleeding and will identify any uterine enlargement in patients with AUB who are older than 45 years as a or irregularity, which can be associated with a structural first-line test. Endometrial sampling also should be per- cause of the acute AUB (leiomyoma). formed in patients younger than 45 years with a history of unopposed estrogen exposure (such as seen in patients Laboratory Testing and Imaging with obesity or polycystic ovary syndrome), failed medical Laboratory evaluation of patients who present with management, and persistent AUB (2). In a stable patient, acute AUB is recommended (Table 1). All adolescents a decision whether to perform a pelvic ultrasound exami- nation should be based on the clinical judgment of the examining clinician. Table 1. Laboratory Testing for the Evaluation of Patients Treatment With Acute Abnormal Uterine Bleeding ^ Limited evidence and expert opinion support recommen- Laboratory Evaluation Specific Laboratory Tests dations for treatment. Choice of treatment for acute AUB depends on clinical stability, overall acuity, suspected Initial laboratory testing Complete blood count etiology of the bleeding, desire for future fertility, and Blood type and cross match underlying medical problems. The two main objectives Pregnancy test of managing acute AUB are: 1) to control the current epi- sode of heavy bleeding and 2) to reduce menstrual blood Initial laboratory evaluation for Partial thromboplastin time loss in subsequent cycles. Medical therapy is considered disorders of hemostasis Prothrombin time the preferred initial treatment (Table 2). However, certain Activated partial thrombo- situations may call for prompt surgical management (6). plastin time Studies of treatments of acute AUB are limited, and only Fibrinogen one treatment (intravenous [IV] conjugated equine estro- gen) is specifically approved by the U.S. Food and Drug Initial testing for von Willebrand factor antigen† Administration for the treatment of acute AUB. von Willebrand disease* Ristocetin cofactor assay† Factor VIII† Medical Management Other laboratory tests to Thyroid-stimulating hormone Hormonal management is considered the first line of consider medical therapy for patients with acute AUB with- Serum iron, total iron binding out known or suspected bleeding disorders. Treatment capacity, and ferritin options include IV conjugated equine estrogen, combined Liver function tests oral contraceptives (OCs), and oral progestins. In one Chlamydia trachomatis randomized controlled trial of 34 women, IV conjugated equine estrogen was shown to stop bleeding in 72% of *Adult women who receive positive results for risk of bleeding disorders or who have abnormal initial laboratory test results for disorders of hemostasis should participants within 8 hours of administration compared undergo testing for von Willebrand disease. Adolescents with heavy menses since with 38% of participants treated with a placebo (7). menarche who present with acute abnormal uterine bleeding also should undergo Little data exist regarding the use of IV estrogen in testing for von Willebrand disease. patients with cardiovascular or thromboembolic risk † Consultation with a hematologist can aid in interpreting these test results. If any factors. of these markers are abnormally low, a hematologist should be consulted. Combined OCs and oral progestins, taken in multi- Data from James AH, Kouides PA, Abdul-Kadir R, Dietrich JE, Edlund M, Federici dose regimens, also are commonly used for acute AUB. AB, et al. Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert One study compared participants who underwent therapy panel. Eur J Obstet Gynecol Reprod Biol 2011;158:124–34; National Heart, Lung, with OCs administered three times daily for 1 week with and Blood Institute. The diagnosis, evaluation, and management of von Willebrand those who underwent therapy with medroxyprogesterone disease. NIH Publication No. 08-5832. Bethesda (MD): NHLBI; 2007. Available at: acetate administered three times daily for 1 week for http://www.nhlbi.nih.gov/guidelines/vwd/vwd.pdf. Retrieved December 5, 2012; and Diagnosis of abnormal uterine bleeding in reproductive-aged women. Practice the treatment of acute AUB (8). The study found that Bulletin No. 128. American College of Obstetricians and Gynecologists. Obstet bleeding stopped in 88% of women who took OCs and Gynecol 2012;120:197–206. 76% of women who took medroxyprogesterone acetate Committee Opinion No. 557 3 Table 2. Medical Treatment Regimens ^ Potential Contraindications and Precautions According to Drug Source Suggested Dose Dose Schedule FDA Labeling* Conjugated equine DeVore GR, Owens O, Kase N. 25 mg IV Every 4–6 hours Contraindications include, but are estrogren Use of intravenous Premarin for 24 hours not limited, to breast cancer, active in the treatment of or past venous thrombosis or dysfunctional uterine arterial thromboembolic disease, bleeding—a double-blind and liver dysfunction or disease. randomized control study. The agent should be used with Obstet Gynecol 1982;59: caution in patients with cardio- 285–91. vascular or thromboembolic risk factors. Combined oral Munro MG, Mainor N, Basu R, Monophasic combined Three times per day for Contraindications include, but are contraceptives† Brisinger M, Barreda L. Oral oral contraceptive that 7 days not limited to, cigarette smoking medroxyprogesterone acetate contains 35 micrograms (in women aged 35 years or older), and combination oral of ethinyl estradiol hypertension, history of deep vein contraceptives for acute uterine thrombosis or pulmonary embolism, bleeding: a randomized known thromboembolic disorders, controlled trial. Obstet Gynecol cerebrovascular disease, ischemic 2006;108:924–9. heart disease, migraine with aura, current or past breast cancer, severe liver disease, diabetes with vascular involvement, valvular heart disease with complications, and major surgery with prolonged immobilization. Medroxypro- Munro MG, Mainor N, Basu R, 20 mg orally Three times per day for Contraindications include, but are gesterone acetate‡ Brisinger M, Barreda L. Oral 7 days not limited to, active or past deep medroxyprogesterone acetate vein thrombosis or pulmonary and combination oral contracep- embolism, active or recent arterial tives for acute uterine bleeding: thromboembolic disease, current or a randomized controlled trial. past breast cancer, and impaired Obstet Gynecol 2006;108:924–9. liver function or liver disease. Tranexamic acid James AH, Kouides PA, 1.3 g orally§ Three times per day Contraindications include, but are Abdul-Kadir R, Dietrich JE, or for 5 days not limited to, acquired impaired Edlund M, Federici AB, et al. 10 mg/kg IV (maximum (every 8 hours ) color vision and current thrombotic Evaluation and management of 600 mg/dose) or thromboembolic disease. The acute menorrhagia in women agent should be used with caution with and without underlying in patients with a history of bleeding disorders: consensus thrombosis (because of uncertain from an international expert thrombotic risks), and concomitant panel. Eur J Obstet Gynecol administration of combined oral Reprod Biol 2011;158:124–34. contraceptives needs to be care- fully considered. Abbreviations: FDA indicates U.S. Food and Drug Administration; IV, intravenously. *The U.S. Food and Drug Administration’s labeling contains exhaustive lists of contraindications for each of these therapies. In treating women with acute abnormal uterine bleeding, physicians often must weigh the relative risks of treatment against the risk of continued bleeding in the context of the patient’s medical history and risk factors. These decisions must be made on a case-by-case basis by the treating clinician. † Other combined oral contraceptive formulations, dosages, and schedules also may be effective. ‡ Other progestins (such as norethindrone acetate), dosages, and schedules also may be effective. § Other dosages and schedules also may be effective. 4 Committee Opinion No. 557 within a median time of 3 days. For all patients, the Surgical Management contraindications to these therapies need to be consid- The need for surgical treatment is based on the clinical ered before administration. Consultation with the Cen- stability of the patient, the severity of bleeding, contra- ters for Disease Control and Prevention’s Medical indications to medical management, the patient’s lack Eligibility Criteria for Contraceptive Use (9, 10) and U.S. of response to medical management, and the underlying Food and Drug Administration labeling information (11) medical condition of the patient. Surgical options include can be helpful in determining which patients may or may dilation and curettage (D&C), endometrial ablation, uter- not be treated with OCs or progestin alone. Other OC ine artery embolization, and hysterectomy. The choice of and progestin formulations and dose schedules may be surgical modality (eg, D&C versus hysterectomy) is based equally effective. on the aforementioned factors plus the patient’s desire Antifibrinolytic drugs, such as tranexamic acid, for future fertility. Specific treatments, such as hysteros- work by preventing fibrin degradation and are effec- copy with D&C, polypectomy, or myomectomy, may be tive treatments for patients with chronic AUB. They required if structural abnormalities are suspected as the have been shown to reduce bleeding in these patients cause of acute AUB. Dilation and curettage alone (with- by 30–55% (12, 13). Tranexamic acid effectively reduces out hysteroscopy) is an inadequate tool for evaluation intraoper-ative bleeding and the need for transfusion in of uterine disorders and may provide only a temporary surgical patients and is likely effective for patients with reduction in bleeding (cycles after the D&C will not be acute AUB, although it has not been studied for this indi- improved) (18). Dilation and curettage with concomitant cation (14, 15). Experts recommend using either oral or hysteroscopy may be of value for those patients in whom IV tranexamic acid for the treatment of acute AUB (15). intrauterine pathology is suspected or a tissue sample is Intrauterine tamponade with a 26F Foley catheter infused desired (18). Case reports of uterine artery embolization with 30 mL of saline solution has been reported to control and endometrial ablation show that these procedures suc- bleeding successfully and also may be considered (15, 16). cessfully control acute AUB (19, 20). Endometrial abla- Once the acute episode of bleeding has been con- tion, although readily available in most centers, should be trolled, multiple treatment options are available for considered only if other treatments have been ineffective long-term treatment of chronic AUB. Effective medical or are contraindicated, and it should be performed only therapies include the levonorgestrel intrauterine system, when a woman does not have plans for future childbear- OCs (monthly or extended cycles), progestin therapy (oral ing and when the possibility of endometrial or uterine or intramuscular), tranexamic acid, and nonsteroidal anti- cancer has been reliably ruled out as the cause of the acute inflammatory drugs (6). If a patient is receiving IV con- AUB. Hysterectomy, the definitive treatment for control- jugated equine estrogen, the health care provider should ling heavy bleeding, may be necessary for patients who do add progestin or transition to OCs. Unopposed estrogen not respond to medical therapy. should not be used as long-term treatment for chronic AUB. Conclusions and Recommendations Patients with known or suspected bleeding disorders may respond to the hormonal and nonhormonal manage- Based on the available evidence and expert opinion, the ment options listed earlier in this section. Consultation American College of Obstetricians and Gynecologists’ with a hematologist is recommended for these patients, Committee on Gynecologic Practice makes the following especially if bleeding is difficult to control or the gyne- conclusions and recommendations: cologist is unfamiliar with the other options for medical The etiologies of acute AUB should be classified based management. Desmopressin may help treat acute AUB on the PALM–COEIN system: Polyp, Adenomyosis, in patients with von Willebrand disease if the patient is Leiomyoma, Malignancy and hyperplasia, Coagulo- known to respond to that agent. It may be administered pathy, Ovulatory dysfunction, Endometrial, Iatro- by intranasal inhalation, intravenously, or subcutaneous- genic, and Not otherwise classified. ly (17). This agent must be used with caution because of Medical management should be the initial treatment the risks of fluid retention and hyponatremia and should for most patients, if clinically appropriate. Options not be administered to patients with massive hemor- rhage who are receiving IV fluid resuscitation because of include IV conjugated equine estrogen, multi-dose issues with fluid overload (15). Recombinant factor VIII regimens of OCs or oral progestins, and tranexamic and von Willebrand factor also are available and may be acid. Decisions should be based on the patient’s required to control severe hemorrhage (5). Other factor medical history and contraindications to therapies. deficiencies may need factor-specific replacement. The need for surgical treatment is based on the Patients with bleeding disorders or platelet function clinical stability of the patient, the severity of bleed- abnormalities should avoid nonsteroidal antiinflamma- ing, contraindications to medical management, the tory drugs because of their effect on platelet aggregation patient’s lack of response to medical management, and their interaction with drugs that might affect liver and the underlying medical condition of the patient. function and the production of clotting factors (17). The choice of surgical modality should be based on Committee Opinion No. 557 5  the aforementioned factors plus the patient’s desire 11. Food and Drug Administration. FDA online label reposito- for future fertility. ry. Available at: http://labels.fda.gov. Retrieved December Once the acute bleeding episode has been controlled, 5, 2012. ^ transitioning the patient to long-term maintenance 12. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy therapy is recommended. menstrual bleeding. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD000249. DOI: 10.1002/ 14651858.CD000249. [PubMed] [Full Text] ^ References 1. Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO 13. Lukes AS, Moore KA, Muse KN, Gersten JK, Hecht classification system (PALM-COEIN) for causes of abnor- BR, Edlund M, et al. Tranexamic acid treatment for mal uterine bleeding in nongravid women of reproductive heavy menstrual bleeding: a randomized controlled trial. age. FIGO Working Group on Menstrual Disorders. Int J Obstet Gynecol 2010;116:865–75. [PubMed] [Obstetrics & Gynaecol Obstet 2011;113:3–13. [PubMed] [Full Text] ^ Gynecology] ^ 2. Diagnosis of abnormal uterine bleeding in reproductive- 14. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, aged women. Practice Bulletin No. 128. American College Mason JM. Tranexamic acid in total knee replacement: a of Obstetricians and Gynecologists. Obstet Gynecol 2012; systematic review and meta-analysis. J Bone Joint Surg Br 120:197–206. [PubMed] [Obstetrics & Gynecology] ^ 2011;93:1577–85. [PubMed] ^ 3. Shankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. 15. James AH, Kouides PA, Abdul-Kadir R, Dietrich JE, von Willebrand disease in women with menorrhagia: a Edlund M, Federici AB, et al. Evaluation and manage- systematic review. BJOG 2004;111:734–40. [PubMed] [Full ment of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an inter- Text] ^ national expert panel. Eur J Obstet Gynecol Reprod Biol 4. Kadir RA, Economides DL, Sabin CA, Owens D, Lee 2011;158:124–34. [PubMed] [Full Text] ^ CA. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet 1998;351:485–9. [PubMed] [Full 16. Hamani Y, Ben-Shachar I, Kalish Y, Porat S. Intrauterine balloon tamponade as a treatment for immune thrombo- Text] ^ cytopenic purpura-induced severe uterine bleeding. Fertil 5. Von Willebrand disease in women. ACOG Committee Steril 2010;94:2769.e13–2769.e15. [PubMed] [Full Text] ^ Opinion No. 451. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1439–43. 17. Kadir RA, Lukes AS, Kouides PA, Fernandez H, Goudemand J. Management of excessive menstrual bleeding in women [PubMed] [Obstetrics & Gynecology] ^ with hemostatic disorders. Fertil Steril 2005;84:1352–9. 6. National Collaborating Centre for Women’s and Children’s [PubMed] [Full Text] ^ Health, National Institute of Clinical Excellence. Heavy menstrual bleeding. Clinical guideline. London: RCOG 18. Bettocchi S, Ceci O, Vicino M, Marello F, Impedovo L, Press; 2007. Available at: http://www.nice.org.uk/nicemedia/ Selvaggi L. Diagnostic inadequacy of dilatation and curet- live/11002/30401/30401.pdf. Retrieved December 5, 2012. tage. Fertil Steril 2001;75:803–5. [PubMed] [Full Text] ^ ^ 19. Nichols CM, Gill EJ. Thermal balloon endometrial 7. DeVore GR, Owens O, Kase N. Use of intravenous Pre- ablation for management of acute uterine hemorrhage. marin in the treatment of dysfunctional uterine bleeding— Obstet Gynecol 2002;100:1092–4. [PubMed] [Obstetrics & a double-blind randomized control study. Obstet Gynecol Gynecology] ^ 1982;59:285–91. [PubMed] [Obstetrics & Gynecology] ^ 20. Bowkley CW, Dubel GJ, Haas RA, Soares GM, Ahn SH. 8. Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Uterine artery embolization for control of life-threatening Oral medroxyprogesterone acetate and combination oral hemorrhage at menarche: brief report. J Vasc Interv Radiol contraceptives for acute uterine bleeding: a randomized 2007;18:127–31. [PubMed] ^ controlled trial. Obstet Gynecol 2006;108:924–9. [PubMed] [Obstetrics & Gynecology] ^ 9. U. S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010;59(RR-4):1–86. [PubMed] [Full Text] ^ Copyright April 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 10. Update to CDC’s U.S. Medical Eligibility Criteria for 20090-6920. All rights reserved. Contraceptive Use, 2010: revised recommendations for ISSN 1074-861X the use of contraceptive methods during the postpar- tum period. Centers for Disease Control and Prevention Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American (CDC). MMWR Morb Mortal Wkly Rep 2011;60:878–83. College of Obstetricians and Gynecologists. Obstet Gynecol 2013; [PubMed] [Full Text] ^ 121:891–6. 6 Committee Opinion No. 557