What is the appropriate management of abnormal uterine bleeding (AUB)?

Management of Abnormal Uterine Bleeding

For general abnormal uterine bleeding in reproductive-age women, first-line medical management includes levonorgestrel-releasing intrauterine devices (20 μg/d), combined oral contraceptives, tranexamic acid, or continuous oral progestins, with the levonorgestrel IUD being the most effective option (71-95% reduction in menstrual blood loss). 1

Initial Assessment and Acute Management

Urgent Evaluation Criteria

Patients require urgent evaluation if they have:

• Hemodynamic instability
• Bleeding saturating a large pad or tampon hourly for ≥4 hours 2
• All reproductive-age women must be tested for pregnancy first 2

Acute Bleeding Stabilization

For hemodynamically unstable patients with acute heavy bleeding:

• High-dose oral or injectable progestin-only medications for short-term control 2
• Tranexamic acid as adjunct therapy 3, 4
• Supportive care including blood transfusion and IV iron as needed 3

Medical Management by Clinical Scenario

Standard Heavy Menstrual Bleeding (No Contraindications)

First-Line Options (in order of effectiveness):

1. Levonorgestrel-releasing IUD (20 μg/d) - Most effective

   • 71-95% reduction in menstrual blood loss
   • Comparable efficacy to endometrial ablation
   • Only progestin IUD with proven efficacy for AUB 2, 1

2. Combined oral contraceptives

   • Reduce bleeding symptoms effectively
   • Provide contraception 1

3. Tranexamic acid (nonhormonal)

   • Effective antifibrinolytic
   • No thrombotic risk in general population 1, 5

4. Continuous oral progestins

   • 87% reduction in bleeding
   • Often results in light bleeding only 2

5. NSAIDs

   • May be combined with hormonal methods
   • Modest effect alone 1

Second-Line Options:

• GnRH agonists (leuprolide acetate) or GnRH antagonists (elagolix, linzagolix, relugolix)
• Reduce bleeding AND tumor volume significantly
• Require add-back estrogen/progestin therapy to mitigate hypoestrogenic effects (hot flashes, bone loss)
• FDA-approved combination therapy available 1

Patients on Anticoagulation

This is a critical special population requiring modified approach:

Preferred Options:

• Levonorgestrel-releasing IUD (20 μg/d) - First choice

  • Minimal systemic absorption
  • Main effect at endometrial level 2, 3

• Progestin-only pills - Safe alternative

  • No increased VTE risk with progestin-only formulations 6

• Tranexamic acid - Generally safe

  • Effective antifibrinolytic without thrombotic complications in most patients 3, 6

AVOID in anticoagulated patients:

• NSAIDs (association with MI and thrombosis) 2
• Combined estrogen-containing oral contraceptives (increased VTE risk)
• Traditional tranexamic acid may need caution in SCAD patients specifically 2

Critical Step: Reassess indication for ongoing anticoagulation and discontinue if appropriate 2

Patients with Cardiovascular Disease (e.g., SCAD)

Specific Contraindications:

• Hormone therapy relatively contraindicated
• NSAIDs should be avoided (MI/thrombosis risk)
• Tranexamic acid should be avoided (MI/thrombosis risk) 2

Recommended Approach:

1. Levonorgestrel IUD (20 μg/d) - Preferred medical option
2. Cyclic oral progestin - If IUD not feasible (87% bleeding reduction)
3. Consider endometrial ablation early - Greater long-term efficacy than oral medical treatment in this population 2

Surgical/Procedural Management

When to Consider Procedural Interventions

Indications:

• Medical management failure
• Patient preference
• Completed fertility
• Need for definitive therapy 1

Procedural Options by Fibroid Location

Pedunculated Submucosal Fibroids (<5 cm):

• Hysteroscopic myomectomy - Procedure of choice
• Shorter hospitalization, faster recovery
• Equivalent symptom improvement to invasive surgery 1

Subserosal or Intramural Fibroids:

• Laparoscopic myomectomy - If fertility desired or smaller fibroids
• Open myomectomy - Multiple fibroids or very large uteri
• Uterine artery embolization (UAE) - No fertility desired
• MR-guided focused ultrasound (MRgFUS) - Selected cases 1

Concurrent Adenomyosis:

• UAE - Usually appropriate (94% short-term improvement, 85% long-term)
• Medical management trial first
• 7% hysterectomy rate for persistent symptoms 1

Definitive Therapy:

• Endometrial ablation - Completed fertility, no structural lesions

  • Second-generation techniques (thermal balloon, microwave, radiofrequency)
  • Particularly useful in cardiovascular disease patients 2

• Hysterectomy - Definitive resolution

  • Most common treatment (75% of fibroid treatments in US)
  • Postmenopausal patients with negative endometrial sampling 1

Management Algorithm

Step 1: Rule out pregnancy, assess hemodynamic stability

Step 2: Determine etiology using PALM-COEIN classification

• Structural (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy
• Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified

Step 3: Imaging if indicated

• Transvaginal ultrasound first-line
• Saline infusion sonohysterography for intracavitary lesions (96-100% sensitivity)
• MRI if ultrasound inadequate or pre-procedural planning 7

Step 4: Endometrial sampling if:

• Age >45 years
• Risk factors for endometrial cancer
• Failed medical management 7, 8

Step 5: Select treatment based on:

• Fertility desires
• Medical comorbidities (especially cardiovascular disease, thrombotic risk)
• Structural vs. non-structural cause
• Patient preference
• Severity of symptoms

Step 6: Trial medical management first unless:

• Acute severe bleeding requiring urgent intervention
• Clear surgical indication (large symptomatic fibroids)
• Patient preference for definitive therapy

Common Pitfalls

1. Failing to test for pregnancy in all reproductive-age women
2. Using combined oral contraceptives or NSAIDs in anticoagulated patients
3. Prescribing hormone therapy to patients with recent SCAD without careful risk assessment
4. Not reassessing anticoagulation indication when bleeding develops
5. Delaying endometrial sampling in women >45 years or with risk factors
6. Using tranexamic acid in SCAD patients (thrombosis risk)
7. Assuming all hormonal therapies are contraindicated in VTE patients (progestin-only options are generally safe)

Multidisciplinary Care

For complex cases (anticoagulation, cardiovascular disease, bleeding disorders):

• Coordinate with hematology for anticoagulation management 3
• Consider dose reduction of anticoagulants (e.g., rivaroxaban 10 mg daily for extended prophylaxis) 3
• Gynecology consultation for procedural options
• Discharge criteria: Stable anticoagulation/menstrual plan, amenorrhea achieved, or anticoagulation discontinued 3