What is the treatment for abnormal uterine bleeding?

Treatment of Abnormal Uterine Bleeding

The first-line treatment for abnormal uterine bleeding (AUB) includes hormonal therapies such as combined hormonal contraceptives or progestin-only options, with the levonorgestrel-releasing intrauterine device (LNG-IUD) being the most effective medical option, reducing menstrual blood loss by 71-95%. 1, 2

Diagnostic Classification

Before initiating treatment, it's important to understand the cause of AUB using the PALM-COEIN classification system:

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

Treatment Algorithm

First-line Medical Therapy

1. Hormonal options:

   • Levonorgestrel-releasing IUD (LNG-IUD): Most effective option with 71-95% reduction in blood loss 2
   • Combined hormonal contraceptives: Effective for both dysmenorrhea and menorrhagia 2
   • Progestin-only contraception: Options include pills, implants, or injections 1

2. Non-hormonal options:

   • NSAIDs: Reduce menstrual blood loss by 26-60% when used for 5-7 days during bleeding 2
   • Tranexamic acid: Reduces blood loss by approximately 50% when used at 3.9-4g/day for 4-5 days 2, 3

When First-line Treatment Fails

If medical treatment fails, is contraindicated, or not tolerated, or if significant intracavitary lesions are present, consider:

1. Further investigation: Imaging (sonohysterography, hysteroscopy) to identify structural causes 1

2. Surgical options:

   • Endometrial ablation: For women who do not desire future fertility 1, 4
   • Hysterectomy: Most definitive treatment when other options fail 1, 5
   • Targeted procedures: Polypectomy or myomectomy for specific structural abnormalities 1

Special Considerations

Ovulatory vs. Anovulatory AUB

• Anovulatory bleeding: Often responds well to hormonal therapy; consider endometrial biopsy in women ≥35 years or with risk factors for endometrial cancer 5
• Ovulatory bleeding (menorrhagia): May be caused by structural abnormalities or coagulation disorders; transvaginal ultrasound is recommended for evaluation 1, 5

Age-specific Considerations

• Perimenopausal women: Higher risk of endometrial hyperplasia/cancer; lower threshold for endometrial sampling 6
• Reproductive-age women: Balance treatment with fertility desires; LNG-IUD provides both contraception and bleeding control 2

Efficacy of Treatment Options

1. LNG-IUD: 71-95% reduction in menstrual blood loss 2
2. Tranexamic acid: 54% reduction in blood loss 3
3. NSAIDs (e.g., mefenamic acid): 20% reduction in blood loss 3
4. Combined hormonal contraceptives: Effective for cycle regulation and reducing blood loss 7

Treatment Pitfalls to Avoid

• Delaying endometrial sampling in women ≥35 years with recurrent anovulation or risk factors for endometrial cancer 5
• Overlooking structural causes that may require specific interventions rather than medical management 1
• Failing to address anemia in women with heavy bleeding; iron supplementation should be included for patients with iron-deficiency anemia 4
• Inappropriate use of tranexamic acid in women with active thromboembolic disease or history/risk of thrombosis 2

Monitoring and Follow-up

• Reassess treatment efficacy after 3 months
• Consider changing treatment approach if inadequate response
• For persistent AUB despite appropriate therapy, consider referral to gynecology for further evaluation

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