transfusion Control of the bleeding is usually accomplished with hormonal treatment, commonly using a combined estrogen and progestin approach ( Table 92.5 ) Estrogen is used to stop the bleeding, by causing vasospasm of the spiral arteries, and support the endometrium A progesterone agent must be administered simultaneously or soon after the administration of estrogen to produce a more stabilized secretory endometrium Any of the OCPs with 0.03 to 0.05 mg of ethinyl estradiol and a progestin provides a convenient means of administering the two hormones together Commonly used pills include ethinyl estradiol 0.03 mg/norgestrel 0.3 mg or ethinyl estradiol 0.05 mg/norgestrel 0.5 mg For brisk bleeding, one tablet may be given up to four times a day until the bleeding stops The medication may then be gradually tapered as long as the bleeding remains ceased (e.g., one tablet three times a day for days, then one tablet two times a day for days, then one tablet a day to complete the active pills in the pack) Note that recurrence of bleeding is common during the pill taper, but is generally much less than the initial bleeding that led to the clinical presentation Although commonly used, there is limited scientific evidence supporting the efficacy of various pill taper protocols and a variety of approaches have been published Obstetrician-gynecologists commonly report tapers with 4-3-2-1 OCP tablets prescribed for consecutive days or 3-3-2-2-1 OCT tablets prescribed for consecutive days A European Consensus group offered four oral options for hormonal treatment of acute bleeding in women without underlying bleeding disorders: birth control pills with either 30 mcg or 50 mcg of ethinyl estradiol (EE) in combination with any progestin to be taken every hours until bleeding stops (with a reevaluation at 48 hours); norethindrone acetate mg to 10 mg every hours; or MPA 10 mg every hours (up to 80 mg/day) Patients should be instructed to continue the pill taper even if bleeding resumes Having the patient increase the hormone dose again is likely to result in a recurrence of bleeding once tapering begins again Nausea is a common side effect of estrogen and can be treated symptomatically with prophylactic antiemetics If the emergency physician is discharging the patient home, provide three prescriptions to the patient The first prescription is for the above taper regimen with instructions to skip the placebo week in the pill pack The second prescription is for a second hormonal pill pack with instructions to take one tablet daily after finishing the taper The third prescription should be for an antiemetic to use during the first days of the taper when high-dose estrogen is being ingested The diagnoses should be included on the prescriptions, as many