From the Guidelines
The management of abnormal uterine bleeding (AUB) should prioritize a thorough evaluation with history, physical examination, laboratory tests, and imaging to determine the etiology, followed by individualized treatment based on the underlying cause, patient age, severity of bleeding, and desire for future fertility. The most recent and highest quality study, 1, published in 2024, provides updated guidance on the management of uterine fibroids, which are a common cause of AUB.
Key Considerations
- Initial management includes a thorough evaluation to determine the etiology of AUB
- For acute heavy bleeding, hormonal treatments are first-line therapy
- For chronic AUB, treatment options include nonsteroidal anti-inflammatory drugs, hormonal contraceptives, tranexamic acid, or the levonorgestrel intrauterine system
- For structural causes like fibroids or polyps, surgical interventions such as hysteroscopic myomectomy, polypectomy, endometrial ablation, or hysterectomy may be necessary
Treatment Options
- Hormonal treatments, such as combined hormonal contraceptives or intravenous conjugated estrogens, for acute heavy bleeding
- Nonsteroidal anti-inflammatory drugs, hormonal contraceptives, tranexamic acid, or the levonorgestrel intrauterine system for chronic AUB
- Surgical interventions, such as hysteroscopic myomectomy, polypectomy, endometrial ablation, or hysterectomy, for structural causes
- Iron supplementation for patients with anemia
Individualized Management
- Management should be individualized based on the specific diagnosis, bleeding severity, and the patient's reproductive goals
- Treatment effectiveness varies based on the underlying cause, with hormonal methods working well for ovulatory dysfunction while structural abnormalities often require procedural interventions
- The patient's desire for future fertility should be taken into account when selecting a treatment option, as some treatments, such as endometrial ablation, are not suitable for patients who wish to become pregnant in the future, as noted in 1.
From the Research
Definition and Classification of Abnormal Uterine Bleeding (AUB)
- Abnormal uterine bleeding (AUB) is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration 2.
- AUB encompasses heavy menstrual bleeding, irregular menstrual bleeding, and intermenstrual bleeding, which are common symptoms among women of reproductive age 2.
- The PALM-COIEN classification is used to categorize AUB into anatomical (PALM) and functional (COIEN) causes 3.
Diagnosis and Evaluation of AUB
- The evaluation of AUB includes self-report and more objective methods, such as blood tests and ultrasound 3.
- Hysteroscopy and endometrial sampling may be required in certain situations to diagnose AUB 3.
- Transvaginal ultrasound is the primary method for screening intracavitary lesions, while saline infusion sonohysterography is more accurate for detecting endometrial polyps and submucous leiomyomas 2.
Medical Management of AUB
- Medical treatment for AUB is based on iron supplementation, hormonal, and non-hormonal therapies 3.
- Options for medical management include:
Surgical Management of AUB
- Surgical treatments for AUB include removal of a focal lesion, endometrial resection or destruction, and hysterectomy 3, 6.
- Hysterectomy offers a definitive surgical approach to AUB and is associated with high levels of patient satisfaction 6.
- Myomectomy may be offered to women wishing to preserve their fertility or avoid hysterectomy 6.
- Minimally invasive options, such as uterine artery embolization, magnetic resonance-guided focused ultrasound, and endometrial ablation, are available, but further research is needed to ensure fertility preservation 6.