Dr. DeCherney and Dr. Yauger reviewed a study by Munro and colleagues that addresses one of the more common problems I see in my general gynecology practice: how to manage acute uterine bleeding. In residency, we commonly treated this condition with Norlestrin (norethindrone acetate 2.5 mg, with ethinyl estradiol 50 mg) 2 or 3 times daily as an outpatient alternative to intravenous estrogen, but noncompliance was high due to nausea. It did lead to rapid cessation of symptoms, however.
Over the years I have found the use of oral contraceptives to be empirically better (in uncontrolled comparison with the medroxyprogesterone acetate used by 2 partners) for the treatment of menometrorrhagia. Most recently, since the introduction of femhrt (norethindrone acetate 1 mg, with ethinyl estradiol 5 μg), I have found that a twice-daily or, in more extreme cases, 3 times daily, regimen works nearly as well as the old regimen, with virtually no nausea, because the total day’s dose of estrogen is lower than 1 standard low-dose pill and is divided over 24 hours. The small amount of estrogen, along with the estrogen-like activity of norethindrone, seems to elicit a more rapid response.
With increasing pressures to limit costs, outpatient alternatives become more important. I also use this femhrt dosage in acute, painful functional ovarian cyst suppression—our most common emergency department gyn consultation request—with excellent, rapid symptom control without nausea. I keep a couple of sample packs in my hospital locker, as it is not on the formulary and, as usual, most of the consults seem to occur in the wee hours of the morning.
Barry A. Bruggers, MD
Cary, NC