What is the initial evaluation and treatment approach for a patient presenting with abnormal uterine bleeding?

From the Guidelines

The initial evaluation of abnormal uterine bleeding (AUB) should include a thorough history, physical examination, pregnancy test, complete blood count, and pelvic ultrasound to determine the cause, as recommended by the most recent guidelines 1. The evaluation process is crucial in identifying the underlying cause of AUB, which can range from structural causes such as polyps, adenomyosis, leiomyoma, and malignancy, to non-structural causes like coagulopathies, ovulatory dysfunction, and iatrogenic etiologies. Key considerations in the evaluation include:

• A thorough medical history to identify potential causes and risk factors
• Physical examination to assess for signs of bleeding or other related conditions
• Laboratory tests such as a complete blood count to evaluate for anemia
• Imaging studies like pelvic ultrasound to identify structural abnormalities Treatment of AUB depends on the etiology, severity of bleeding, and the patient's reproductive goals. For acute heavy bleeding, options include:
• Tranexamic acid (1000 mg orally three times daily for up to 5 days during bleeding) 1
• High-dose combined hormonal contraceptives (one pill three times daily for 7 days, then daily for 3 weeks) For ongoing management, options include:
• Hormonal therapies such as combined hormonal contraceptives (daily), progestin-only pills (norethindrone acetate 5-10 mg daily), or levonorgestrel IUD insertion
• Non-hormonal options like NSAIDs (e.g., ibuprofen 600 mg three times daily during menses) or tranexamic acid during bleeding episodes
• Iron supplementation (ferrous sulfate 325 mg daily) for patients with anemia Surgical interventions like endometrial ablation or hysterectomy may be considered for patients who fail medical management or have specific pathologies. Endometrial sampling is necessary for patients over 45 or those with risk factors for endometrial cancer, as it is a critical step in ruling out malignancy 1. The treatment approach should be individualized based on the underlying cause, with structural abnormalities potentially requiring specific interventions. It is essential to prioritize the patient's quality of life, reproductive goals, and overall health when selecting a treatment option. By following a comprehensive evaluation and treatment plan, healthcare providers can effectively manage AUB and improve patient outcomes.

From the FDA Drug Label

Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. Secondary amenorrhea, abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 2. 5 to 10 mg norethindrone acetate tablets may be given daily for 5 to 10 days to produce secretory transformation of an endometrium that has been adequately primed with either endogenous or exogenous estrogen. Norethindrone Acetate Tablets, USP are indicated for the treatment of secondary amenorrhea, endometriosis, and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer.

The initial evaluation and treatment approach for a patient presenting with abnormal uterine bleeding should involve:

• Ruling out organic pathology such as submucous fibroids or uterine cancer
• Considering hormonal imbalance as a potential cause
• Using norethindrone acetate tablets at a dose of 5 to 10 mg daily for 5 to 10 days to produce secretory transformation of the endometrium 2
• Planning menstrual cycling with norethindrone acetate tablets for patients with a history of recurrent episodes of abnormal uterine bleeding 2 Key points to consider in the treatment approach include:
• Dosage adaptation to the individual patient's response
• Therapeutic response to norethindrone acetate tablets
• Contraindications for use with concomitant estrogen therapy in postmenopausal women for endometrial protection 2

From the Research

Initial Evaluation

• The initial evaluation of a patient presenting with abnormal uterine bleeding involves a thorough history, physical examination, and laboratory testing, including a pregnancy test and complete blood count 3, 4, 5, 6.
• The evaluation should also consider the patient's medical history, risk factors, and potential structural causes of the bleeding 3, 7, 4, 5, 6.
• Transvaginal ultrasonography is the preferred imaging modality and is indicated if a structural etiology is suspected or if symptoms persist despite appropriate initial treatment 3, 4, 6.

Classification and Diagnosis

• The acronym PALM-COEIN can be used to classify abnormal uterine bleeding into structural (PALM) and nonstructural (COEIN) etiologies 4.
• Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure 4, 5.
• Diagnostic techniques available for the evaluation of abnormal uterine bleeding include endometrial biopsy, dilatation and curettage, transvaginal ultrasonography, and hysteroscopy 5, 6.

Treatment Approach

• Medical management is the first-line approach for treating abnormal uterine bleeding, and the choice of treatment depends on the underlying cause and the patient's medical history 3, 7, 4, 6.
• Treatment options for anovulatory dysfunctional uterine bleeding include oral contraceptive pills or cyclic progestins 3, 7, 6.
• Menorrhagia can be managed with nonsteroidal anti-inflammatory drugs, the levonorgestrel intrauterine contraceptive device, or tranexamic acid 3, 7, 4, 6.
• Surgical management may include hysterectomy or less invasive, uterus-sparing procedures, such as polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation 3, 7, 4, 6.