What are the treatment options for managing uterine bleeding?

From the Guidelines

Treatment options for managing uterine bleeding include both medical and surgical approaches, with first-line medical treatments often including hormonal medications such as combined oral contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs, as recommended by the most recent guidelines 1. The choice of treatment depends on the underlying cause of bleeding, the patient's age, desire for future fertility, and severity of symptoms.

• Medical treatments may include:
  • Combined oral contraceptives (30-35 mcg ethinyl estradiol) to reduce bleeding by 40-50% by stabilizing the endometrial lining
  • Tranexamic acid (1000-1300 mg three times daily during heavy bleeding days) to reduce bleeding by about 40%
  • Nonsteroidal anti-inflammatory drugs like ibuprofen (600-800 mg three times daily during menses) to decrease bleeding by 20-40% by reducing prostaglandin production
• For longer-term management, levonorgestrel-releasing intrauterine devices (Mirena, 20 mcg/day) can reduce bleeding by up to 90% over 3-6 months, as supported by recent studies 1. In cases where medical management fails, surgical options include endometrial ablation (destroying the uterine lining), uterine artery embolization (blocking blood supply to fibroids), myomectomy (removing fibroids while preserving the uterus), or hysterectomy (complete uterus removal) for definitive treatment, with the most recent guidelines emphasizing the importance of considering the patient's individual needs and preferences 1. Acute heavy bleeding may require immediate intervention with high-dose estrogen or tranexamic acid to stabilize the patient before determining long-term management, as recommended by recent studies 1.

From the FDA Drug Label

Medroxyprogesterone acetate, administered parenterally in the recommended doses to women with adequate endogenous estrogen, transforms proliferative endometrium into secretory endometrium. Medroxyprogesterone acetate inhibits (in the usual dose range) the secretion of pituitary gonadotropin which, in turn, prevents follicular maturation and ovulation.

The hormone medroxyprogesterone acetate works by transforming the endometrium from a proliferative state to a secretory state, and by inhibiting the secretion of pituitary gonadotropin, which prevents follicular maturation and ovulation.

• For managing uterine bleeding, oral therapy is recommended instead of medroxyprogesterone acetate injection, due to its prolonged action and the resulting difficulty in predicting the time of withdrawal bleeding 2.

From the Research

Treatment Options for Managing Uterine Bleeding

The treatment options for managing uterine bleeding include hormonal contraceptives, such as combined oral contraceptives (COCs) and the levonorgestrel intrauterine system (LNG IUS) 3, 4.

• Combined Oral Contraceptives (COCs): COCs are effective in reducing menstrual bleeding and improving quality of life 3, 4. A study comparing the 52-mg levonorgestrel intrauterine system with COCs found that both treatments improved bleeding-related quality of life, but there were no significant differences between the two treatments at 6 and 12 months 3.
• Levonorgestrel Intrauterine System (LNG IUS): The LNG IUS is also effective in reducing menstrual bleeding and is considered a good option for women with heavy menstrual bleeding 3, 4. A review of studies found that the LNG IUS was more effective than COCs in reducing menstrual bleeding, but the evidence was of low quality 4.
• Extended-Cycle Regimens: Extended-cycle regimens, which involve taking active pills for 84 days followed by 7 days of placebo or a low-dose estrogen pill, have been shown to be effective in reducing menstrual bleeding 5, 6. A study comparing an extended-cycle regimen with a conventional-cycle regimen found that the extended-cycle regimen resulted in a lower number of bleeding days and a more favorable bleeding pattern 5.

Hormonal Mechanisms

Hormonal contraceptives work by regulating the menstrual cycle and reducing menstrual bleeding. The exact mechanisms are not fully understood, but it is thought that they work by thinning the endometrium, reducing ovulation, and altering the hormonal balance 4, 7.

• Estrogen and Progesterone: Estrogen and progesterone are the two main hormones involved in the menstrual cycle. Estrogen stimulates the growth of the endometrium, while progesterone helps to maintain the endometrium and prepare it for implantation of a fertilized egg 4, 7.
• Progestin-Only Contraceptives: Progestin-only contraceptives, such as the LNG IUS, work by thinning the endometrium and reducing menstrual bleeding. They can also cause irregular bleeding and spotting, especially in the first few months of use 7.