What are the management options for abnormal uterine bleeding?

From the Guidelines

Management of abnormal uterine bleeding (AUB) should be individualized based on the underlying cause, patient age, desire for fertility, and symptom severity, with first-line treatment often including hormonal medications such as combined hormonal contraceptives or progestin-only options, as recommended by the most recent guidelines 1. The treatment approach for AUB can be categorized into medical and surgical options. Medical management includes hormonal medications, such as:

• Combined hormonal contraceptives (estrogen and progestin), which can reduce bleeding by 50-60% by stabilizing the endometrium, and can be taken cyclically or continuously, with pills like ethinyl estradiol/norethindrone 35mcg/1mg daily 1.
• Progestin-only options, including oral medroxyprogesterone acetate 10mg daily for 10-14 days per month, the levonorgestrel intrauterine system (Mirena), which reduces bleeding by 80-90% over 3-6 months, or depot medroxyprogesterone acetate injections (150mg IM every 3 months) 1. For acute heavy bleeding, non-hormonal options such as:
• Tranexamic acid 1300mg three times daily during menses, which can reduce blood loss by 40-50% by inhibiting fibrinolysis 1.
• NSAIDs like ibuprofen 600mg three times daily during menses, which can decrease bleeding by 20-40% through prostaglandin reduction 1. Surgical options are considered for patients with structural abnormalities, such as fibroids or polyps, and include:
• Hysteroscopic myomectomy
• Endometrial ablation
• Uterine artery embolization
• Hysterectomy for definitive treatment 1. It is essential to note that iron supplementation (ferrous sulfate 325mg daily) is crucial for patients with anemia to prevent long-term morbidity and mortality associated with chronic blood loss 1. The most recent guidelines emphasize the importance of individualizing treatment based on the specific cause of AUB, with hormonal options preferred for those with anovulatory bleeding and structural interventions for those with fibroids or polyps 1.

From the FDA Drug Label

Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use Non-hormonal causes should be considered and adequate diagnostic measures taken to rule out malignancy or pregnancy in the event of breakthrough bleeding, as in the case of any abnormal vaginal bleeding. If pathology has been excluded, time or a change to another formulation may solve the problem.

The management options for abnormal uterine bleeding include:

• Adequate diagnostic measures to rule out pregnancy or malignancy 2
• Time to see if the issue resolves on its own 2
• Change to another preparation or formulation of oral contraceptive 2
• Change to an oral contraceptive with a higher estrogen content, but this should be done with caution due to the increased risk of thromboembolic disease 2
• Considering non-hormonal causes of bleeding and taking diagnostic measures to rule out other conditions 2

From the Research

Management Options for Abnormal Uterine Bleeding

The management of abnormal uterine bleeding can be divided into medical and surgical options.

• Medical management options include:
  • Combination oral contraceptives or progestins to regulate menstrual cycles 3
  • Cyclic or continuous progestin for histologic findings of hyperplasia without atypia 3
  • Levonorgestrel-releasing intrauterine system for menorrhagia 3
  • Oral progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs for menorrhagia 3
  • Tranexamic acid for ovulatory bleeding 3
• Surgical management options include:
  • Polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation when clear structural causes are identified or medical management is ineffective 3
  • Hysterectomy as the most definitive treatment 3

Specific Management Algorithms

There are specific management algorithms for abnormal uterine bleeding, including:

• An algorithm based on a systematic review of the literature and actual management of patients seen in a gynecology clinic 4
• Algorithms for treating abnormal uterine bleeding in people using levonorgestrel intrauterine devices, depo-medroxyprogesterone acetate, progestin implant, progestin-only pills, and combined hormonal contraception 5

Medical Management for Specific Causes

Medical management options are available for specific causes of abnormal uterine bleeding, including:

• Anovulatory dysfunctional uterine bleeding, which can be treated with medroxyprogesterone acetate, oral contraceptives, or clomiphene citrate 6
• Ovulatory dysfunctional uterine bleeding, which can be treated with prolonged progestin use, oral contraceptives, nonsteroidal anti-inflammatory drugs, antifibrinolytic agents, or danazol 6
• Abnormal uterine bleeding associated with hormonal contraception, which can be treated with nonsteroidal anti-inflammatory drugs, estradiol, or changes to the contraceptive method 5

Importance of Accurate Diagnosis

Accurate diagnosis is crucial in managing abnormal uterine bleeding, including:

• Distinguishing between anovulatory and ovulatory bleeding patterns 3, 6
• Identifying structural and endocrinologic anomalies or lifestyle factors that may explain the bleeding 7
• Using appropriate ancillary tests to identify the cause of the bleeding 7