What is the management for persistent abnormal uterine bleeding?

Management of Persistent Abnormal Uterine Bleeding

The most effective first-line medical treatment for persistent abnormal uterine bleeding is the levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95% and should be considered for women with heavy or persistent bleeding. 1

Diagnostic Approach

Before initiating treatment, a thorough evaluation is essential to identify the underlying cause:

1. Apply PALM-COEIN classification system to categorize causes:

   • Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
   • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 2, 1

2. Essential diagnostic tests:

   • Complete blood count to assess anemia
   • Pregnancy test (β-hCG)
   • TSH and prolactin levels
   • Transvaginal ultrasonography as first-line imaging 1
   • Saline infusion sonohysterography for suspected intracavitary lesions 2, 1
   • Endometrial biopsy for women ≥35 years with recurrent anovulation or risk factors for endometrial cancer 1, 3

Treatment Algorithm

Acute Heavy Bleeding Management

1. Combined hormonal contraceptives:

   • Multi-dose regimen (3 tablets daily for 7 days) for acute bleeding control 4
   • Continue with maintenance dose after bleeding control

2. High-dose progestin therapy:

   • Medroxyprogesterone acetate 20-40 mg daily or norethindrone acetate 5-10 mg daily 4
   • Note: Oral medroxyprogesterone is preferred over injectable for abnormal uterine bleeding 5

3. Tranexamic acid:

   • Reduces menstrual blood loss by approximately 50%
   • Dosage: 3.9-4g/day for 4-5 days starting from first day of menstrual cycle
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

Long-term Management Options

1. Levonorgestrel-releasing IUD (first-line):

   • Most effective medical option, reducing blood loss by 71-95% 1
   • Provides contraception and treats bleeding simultaneously

2. Combined hormonal contraceptives:

   • Effective for regulating cycles and reducing bleeding
   • Contraindicated in women >35 who smoke or have other cardiovascular risk factors 1

3. Progestin-only options:

   • Oral progestins for 21 days per month
   • Implants or injections also effective 1, 3

4. NSAIDs:

   • Reduce menstrual blood loss by 26-60%
   • Use for 5-7 days during bleeding days 1
   • Can be combined with hormonal methods

Surgical Options (when medical management fails)

1. Targeted procedures for specific structural abnormalities:

   • Polypectomy
   • Myomectomy
   • Uterine artery embolization 1

2. Endometrial ablation:

   • For women who have completed childbearing
   • Not first-line but effective when medical management fails 2
   • Potential complications include postablation syndrome, synechiae, and cervical stenosis 2

3. Hysterectomy:

   • Most definitive treatment when other options fail
   • Consider when significant intracavitary lesions are present or medical treatment is contraindicated 2, 1

Special Considerations

• Perimenopausal women have higher risk of endometrial hyperplasia/cancer and require lower threshold for endometrial sampling 1

• Coagulation disorders (e.g., von Willebrand disease) should be considered in women with persistent heavy bleeding 1, 3

• Endometrial hyperplasia findings:

  • Without atypia: Treat with cyclic or continuous progestin
  • With atypia or adenocarcinoma: Refer to gynecologist or gynecologic oncologist 3

• Hormonal contraception-related bleeding:

  • For LNG-IUD users with persistent bleeding: NSAIDs first-line, followed by short-term estradiol if needed 6
  • For progestin-only method users: Consider adding combined oral contraceptives temporarily 6

By following this systematic approach to persistent abnormal uterine bleeding, most patients can achieve significant improvement in symptoms and avoid unnecessary surgical interventions.