What treatment is recommended to halt bleeding from Dysfunctional Uterine Bleeding (DUB)?

Treatment Options for Dysfunctional Uterine Bleeding (DUB)

For halting active bleeding from DUB, the first-line treatment is adding tranexamic acid (TXA) to combined oral contraceptive pills (COCPs), which is recommended by 53% of specialists according to the most recent guidelines. 1

First-Line Treatment Algorithm

1. For active bleeding requiring immediate control:

   • Combined hormonal contraceptives (CHCs) with tranexamic acid (TXA)
   • If bleeding is severe, high-dose estrogen therapy may be used to rapidly control acute bleeding 2

2. If already on COCPs but still experiencing bleeding:

   • Add TXA to COCP regimen (53% of specialists recommend this approach) 1
   • TXA dosing: 5-7 days of treatment 1

3. If COCPs are contraindicated:

   • Consider levonorgestrel-releasing intrauterine device (LNG-IUD) (19% of specialists recommend this) 1
   • NSAIDs for 5-7 days (effective for both Cu-IUD and LNG-IUD users) 1

Second-Line Options (if first-line fails)

1. Discontinue COCPs and insert LNG-IUD (51% of specialists recommend this) 1

   • LNG-IUD is highly effective, resulting in 71-95% reduction in menstrual blood loss 1

2. COCP with TXA (13% of specialists) 1

3. COCP with desmopressin (DDAVP) (13% of specialists) 1

4. For patients who cannot use hormonal methods:

   • NSAIDs (can reduce blood loss by 25-35%, with greater reduction in women with more excessive bleeding) 3
   • Antifibrinolytic drugs like TXA (can reduce menstrual blood loss by 50%) 3

Third-Line Options

1. Combined DDAVP/COCP/TXA (34% of specialists recommend) 1

2. DDAVP with COCP (14% of specialists) 1

3. DDAVP with TXA (13% of specialists) 1

4. Progestin-only options:

   • Norethindrone acetate: 2.5-10 mg daily for 5-10 days to produce secretory transformation of the endometrium 4
   • For recurrent episodes, planned menstrual cycling with norethindrone acetate may be beneficial 4

Surgical Options (when medical treatment fails)

If medical treatment fails, is contraindicated, or not tolerated:

• Endometrial ablation techniques (thermal balloon, microwave, radiofrequency) 1
• Hysterectomy (definitive treatment when all other options have failed) 1, 2

Important Considerations

• Rule out underlying causes: Before treating DUB, confirm diagnosis and rule out endometrial and structural pathologies 1

• Bleeding disorders: Consider screening for von Willebrand's disease, which is present in approximately 1% of the population and can be misdiagnosed as DUB 2

• Hormonal contraindications: For women with cardiovascular disease or other contraindications to hormonal therapy, careful clinical judgment is required 1

• Monitoring: No routine follow-up visit is required, but advise patients to return if they experience side effects, problems, or want to change methods 1

• Pitfall to avoid: Don't assume all abnormal bleeding is DUB without proper investigation. Endometrial biopsy is preferred over dilation and curettage for diagnosing endometrial hyperplasia or cancer due to being less invasive, safer, and lower cost 1

Special Populations

• Adolescents: Anovulation is very common in the first 2-3 post-menarchal years due to immaturity of the hypothalamic-pituitary-ovarian axis. Medroxyprogesterone acetate can be administered orally once daily for 10 days each month for ≥3 months 5, 2

• Perimenopausal women: May be treated with cyclic progestin or cyclic conjugated equine estrogens with medroxyprogesterone acetate. Low-dose combination oral contraceptives may be used if the patient is a nonsmoker and has no evidence of vascular disease 2