Gynecology: ESRD & uterine bleeding

PCP submission

23F w/ ESRD presenting with persistent bleeding x 9 months. Patient reports that she started getting depo shot multiple months ago. Got 3 shots total. At some point early in course of being on Depo she started having menstrual bleeding requiring use of pad but not incredibly heavy. It has basically been persistent since then. Is not pregnant. Last Depo shot was ~4 months ago and is still bleeding.

Can bleeding be attributed to Depo? If so, I expect it will wear off soon. However is there anything I can give her in the meantime to stop bleeding while waiting for this.

Specialist response

Thanks for this consult. The irregular bleeding she was experiencing was likely related to the depo. Unfortunately depo has an unpredictable bleeding pattern; 25 percent of users will discontinue DMPA in the first year because of dissatisfaction with bleeding patterns. The bleeding she is now experiencing is likely a progesterone-withdrawal bleed, as she is one month overdue for her depo, so the drop in progesterone results in endometrial shedding. To stabilize the lining, you could prescribe 2-4 weeks of combined oral contraceptive pills. Alternatively, you could do a 5 day course of tranexamic acid. Studies of breakthrough bleeding on patients using progesterone-only contraception (depo, pills, etc) found that a course of tranexamic acid 250mg orally four times per day for five days was effective in halting bleeding.

PCP follow up

Ok great. Thanks. That is very helpful. She has a history of ESRD on HD via a graft and significant depression. Any contraindication to the tranexamic acid or OCPs with the ESRD on dialysis?

Specialist follow up

Estrogen use and tranexamic acid is permissible in this patients. Contraindications to estrogen include a history of VTE or stroke, liver disease (cirrhosis, hepatocellular adenoma), migraines with aura, or cardiac disease (ischemic heart disease, valvular disease, etc). Since she is young and her only comorbidity is renal, OCPs are considered safe. Contraindications to tranexamic acid include history of an unprovoked VTE or acquired color blindness.