What is the treatment for abnormal uterine bleeding?

Treatment of Abnormal Uterine Bleeding

Medical treatments including progestin-only contraception and combined hormonal contraception are the first-line therapies for abnormal uterine bleeding associated with ovulatory dysfunction, while surgical options such as endometrial ablation and hysterectomy should be considered when medical treatment fails, is contraindicated, or is not tolerated. 1

Diagnostic Approach

Before initiating treatment, proper classification and diagnosis are essential:

• Use the PALM-COEIN classification system to categorize abnormal uterine bleeding:

  • Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
  • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 1

• Key diagnostic tests:

  • Pregnancy test (β-hCG)
  • TSH and prolactin levels
  • Transvaginal ultrasound (first-line imaging) 1
  • Endometrial biopsy (for women ≥35 years with recurrent anovulation or younger women with risk factors for endometrial cancer) 2
  • Saline infusion sonohysterography (when polyps are suspected) 1
  • MRI (when ultrasound cannot adequately visualize the endometrium) 1

Treatment Algorithm

1. Acute Abnormal Uterine Bleeding

For hemodynamically unstable patients or severe bleeding:

• High-dose oral or injectable progestin-only medications for short-term control 3
• Multidose combined oral contraceptive regimen 3
• Tranexamic acid (if no contraindications) 3

2. Chronic Abnormal Uterine Bleeding

A. Ovulatory Dysfunction-Related Bleeding:

First-line options:

• Levonorgestrel-releasing intrauterine system (LNG-IUS) - most effective approach with 71-95% reduction in menstrual blood loss 1, 2
• Combined hormonal contraceptives 1
• Cyclic oral progestins (reduces bleeding by approximately 87%) 1

Second-line options:

• Tranexamic acid - FDA-approved for ovulatory bleeding but expensive 2
• NSAIDs - can be used in combination with hormonal methods 3

B. Structural Causes:

For endometrial polyps:

• Hysteroscopic polypectomy 4

For submucosal fibroids:

• Hysteroscopic myomectomy
• Uterine artery embolization
• GnRH agonists (for preoperative reduction of fibroid size) 1

For adenomyosis:

• LNG-IUS
• Combined hormonal contraceptives
• Continuous oral progestins 3

3. When Medical Management Fails

Consider surgical options:

• Endometrial ablation techniques (thermal balloon, microwave, radiofrequency) 1, 4
• Hysterectomy (most definitive treatment) 2

Special Considerations

• Perimenopausal women: Higher risk of endometrial hyperplasia/cancer; lower threshold for endometrial biopsy 4
• Women with bleeding disorders: All hormonal methods and tranexamic acid are suitable 3
• Women on anticoagulation therapy: Consider progestin-only methods 3
• Adolescents: Anovulatory bleeding common; hormonal regulation usually effective 1

Efficacy of Treatments

• LNG-IUS: 71-95% reduction in menstrual blood loss 1
• Tranexamic acid: 54% reduction in blood loss 5
• Mefenamic acid (NSAID): 20% reduction in blood loss 5
• Ethamsylate: Not effective for reducing menstrual blood loss 5

Common Pitfalls to Avoid

1. Failing to rule out pregnancy, malignancy, or coagulopathy before initiating treatment
2. Using NSAIDs or tranexamic acid in women with SCAD (spontaneous coronary artery dissection) due to increased risk of MI and thrombosis 1
3. Delaying endometrial biopsy in women ≥35 years with recurrent anovulation
4. Overlooking the need for iron supplementation in women with anemia from chronic heavy bleeding
5. Continuing ineffective medical therapy without considering structural causes or surgical options

By following this structured approach to abnormal uterine bleeding, clinicians can effectively manage this common condition while minimizing morbidity and improving quality of life.