What is the recommended conservative management for uterine bleeding?

From the Guidelines

Conservative management for uterine bleeding should prioritize non-hormonal options, such as tranexamic acid (1000-1300 mg three times daily during bleeding) and nonsteroidal anti-inflammatory drugs like ibuprofen (600-800 mg three times daily during menses), as first-line treatments to reduce bleeding symptoms and improve quality of life. According to the most recent guidelines, including the U.S. Selected Practice Recommendations for Contraceptive Use, 2024 1, and the ACR Appropriateness Criteria for Management of Uterine Fibroids: 2023 Update 1, these non-hormonal options are effective in reducing bleeding symptoms and can be used in conjunction with hormonal treatments.

The management of uterine bleeding should consider the following key points:

• Explore patient goals, including continued method use or method discontinuation, and provide reassurance and advise the patient to contact their provider at any time to discuss bleeding irregularities or other side effects 1
• Consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, and treat the condition or refer for care if necessary 1
• Non-hormonal options, such as tranexamic acid and NSAIDs, can be used to reduce bleeding symptoms and are effective in improving quality of life 1
• Hormonal treatments, including combined hormonal contraceptives and oral progestins, can be used to regulate the menstrual cycle and reduce bleeding, but should be considered based on patient preferences, contraceptive needs, and medical history 1

In terms of specific treatment options, the following can be considered:

• Tranexamic acid (1000-1300 mg three times daily during bleeding) to inhibit fibrinolysis and reduce bleeding symptoms 1
• Nonsteroidal anti-inflammatory drugs like ibuprofen (600-800 mg three times daily during menses) to reduce prostaglandin production and bleeding symptoms 1
• Combined hormonal contraceptives (containing estrogen and progestin) taken cyclically or continuously to regulate the menstrual cycle and reduce bleeding 1
• Oral progestins like medroxyprogesterone acetate (10-20 mg daily for 10-14 days per month) or norethindrone acetate (5-10 mg daily) to reduce bleeding symptoms 1

It is essential to note that treatment choice depends on the underlying cause of bleeding, patient preferences, contraceptive needs, and medical history, and should be individualized to each patient's specific needs. Iron supplementation (325 mg ferrous sulfate 1-3 times daily) should be added if anemia is present to improve quality of life and reduce morbidity.

From the FDA Drug Label

What is progesterone capsules used for? Treatment of Menstrual Irregularities Progesterone capsules are used for the treatment of secondary amenorrhea (absence of menstrual periods in women who have previously had a menstrual period) due to a decrease in progesterone When you do not produce enough progesterone, menstrual irregularities can occur. If your healthcare provider has determined your body does not produce enough progesterone on its own, progesterone capsules may be prescribed to provide the progesterone you need

The recommended conservative management for uterine bleeding is to take progesterone capsules, as they are used to treat menstrual irregularities, including secondary amenorrhea, which is the absence of menstrual periods in women who have previously had a menstrual period due to a decrease in progesterone.

• The dosage is 400 mg at bedtime for 10 days for secondary amenorrhea 2.
• Progesterone capsules are to be taken at bedtime as some women become very drowsy and/or dizzy after taking progesterone capsules 2.
• It is essential to follow the healthcare provider's instructions and take the medication as prescribed.
• If you experience any symptoms, such as difficulty swallowing, discuss them with your healthcare provider right away 2.

From the Research

Conservative Management of Uterine Bleeding

The conservative management of uterine bleeding involves several medical and non-surgical approaches. The following are some of the recommended options:

• Medical management is the first-line approach for treating abnormal uterine bleeding, once structural causes have been excluded 3.
• Determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen 3.
• For acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options 3.
• Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy 3, 4.
• Nonsteroidal anti-inflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding 3, 5.

Treatment Options

The following are some of the treatment options for uterine bleeding:

• Levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective treatment for heavy menstrual bleeding, reducing menstrual blood loss by up to 90% 6.
• Tranexamic acid is an effective treatment for heavy menstrual bleeding, reducing menstrual blood loss by approximately 50% 4, 5, 7.
• Combined oral contraceptives are also effective in reducing menstrual blood loss and can be used to treat heavy menstrual bleeding 3, 4, 7.
• Progestin-only methods, such as oral progestins or injectable progestins, can be used to treat heavy menstrual bleeding, especially in women who cannot use estrogen-containing products 3.

Patient-Specific Considerations

The following are some patient-specific considerations for conservative management of uterine bleeding:

• Women with inherited bleeding disorders can use hormonal methods, such as combined oral contraceptives or progestin-only methods, as well as tranexamic acid to treat abnormal uterine bleeding 3.
• Women on anticoagulation therapy should consider using progestin-only methods or a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding 3.
• Women with leiomyomas may benefit from gonadotropin-releasing hormone agonists or progestin-only methods to treat their heavy menstrual bleeding 3, 7.