Women who experience significant daily bleeding for a very long time (weeks) sometimes develop another kind of problem unique to this circumstance, denuding of the uterine lining.

Normally, small breaks or tears in the uterine lining are promptly repaired. For women who have been bleeding for weeks, with the accompanying uterine cramping, the uterine lining becomes very nearly completely lost.

There is so little endometrium left that the woman will have difficulty achieving repair and restoration of the normal lining without external assistance. A common example of this situation would be a teenager who has been bleeding for many weeks but who, through embarrassment, has not sought medical attention. On arrival, she continues to bleed small amounts of bright red blood. She is profoundly anemic, with a hemoglobin of 7.0.

These patients do not respond to simple BCP treatment because the BCPs are so weak in estrogen and so strong in progestin that the uterine lining barely has a chance to grow and cover up the denuded, bleeding areas inside the uterus.

These patients need strong doses of plain estrogen, to effectively stimulate the remaining uterine lining (causing it to proliferate). Premarin, 2.5 to 5 mg PO per day, or IV (25 mg slowly over a few hours) will provide this strong stimulus to the uterine lining and if combined with bedrest, will usually slow or stop the bleeding significantly within 24 hours. This is because the estrogen is stimulating the uterine lining to grow lush and thick.

The estrogen is continued for several days, but at lower dosages (1.25 to 2.5 mg per day) until the bleeding completely stops. Then, progesterone is added (Provera 5-10 mg PO per day) for 5-10 days. Progesterone is necessary at this point because the lush, thick uterine lining is also very fragile and easily broken. Progesterone provides a structural integrity to the uterine lining, making it less likely to tear or break.

Once a normal, thick, well-supported lining has been re-established, first with estrogen, then with the addition of progesterone, it will need to be shed, just like a normal lining is shed once a month. Stopping all medication will trigger a normal menstrual flow about 3 days later. The lining will have been restored and the vicious cycle of bleeding leading to more endometrial loss leading to more bleeding will be broken. Future periods may then be normal, although many physicians will start BCPs at that point to prevent recurrence of the constant bleeding episode.