proliferation, and reducing endometrial tissue prostaglandin production Patients who report persistent pain during the week of placebo pills may be considered for an extended cycle regimen (e.g., prescribing a 91-day pack rather than the standard 28-day pack) The combined contraceptive transdermal patch (Xulane) or vaginal ring (NuvaRing or Annovera) delivers similar results as OCPs Any patient who is sexually active should be counseled about the value of hormonal medications for birth control as well Before initiating any therapy containing estrogen, the patient should be assessed for any contraindication to estrogen (described in detail under Abnormal Uterine Bleeding section) Patients in whom estrogen is contraindicated or not preferable can try a progestin-only medications The injectable depot medroxyprogesterone (DepoProvera) is particularly effective in suppressing ovulation and alleviating pain from dysmenorrhea and can be administered every 12 weeks Implantable subdermal progestin (Nexplanon) and progestin-releasing IUDs (Mirena) may also be longer-acting alternatives to treat dysmenorrhea Most patients with primary dysmenorrhea will respond to NSAIDs and hormonal medications within months Patients whose menstrual-associated pain continue to be severe despite months of NSAIDs and hormonal management should be assessed for dysmenorrhea secondary to endometriosis or other pelvic pathology A laparoscopy may be performed to evaluate for endometriosis ABNORMAL UTERINE BLEEDING Goals of Treatment The goal for the ED physician is to reduce the patient’s vaginal bleeding in a prompt yet safe manner CLINICAL PEARLS AND PITFALLS The physician should assess for signs for hemodynamic instability, including checking orthostatic vital signs and hemoglobin The differential diagnosis for abnormal uterine bleeding (AUB) should include hematologic disorders, such as von Willebrand disease and other coagulation disorders Assess whether there are any contraindications for administering an estrogen-containing therapy Background