What are the treatment options for symptomatic management of Abnormal Uterine Bleeding (AUB)?

Symptomatic Management of Abnormal Uterine Bleeding (AUB)

For symptomatic management of abnormal uterine bleeding, medical therapy should be the first-line treatment, with options including tranexamic acid, NSAIDs, hormonal contraceptives, and selective progesterone receptor modulators, before considering surgical interventions. 1, 2

Initial Medical Management Options

First-Line Medications

1. Tranexamic acid

   • Reduces blood loss by approximately 50%
   • Dosing: Take for 4-5 days starting from first day of menstrual cycle
   • Non-hormonal option suitable for women with contraindications to hormonal therapy
   • Can be used when immediate pregnancy is desired 1, 3

2. NSAIDs (Ibuprofen, Naproxen)

   • Reduces blood loss by 25-39%
   • Dosing: Take for 5-7 days during bleeding episodes
   • Works by inhibiting prostaglandin synthesis
   • Ibuprofen has been shown to reduce elevated prostaglandin activity in menstrual fluid 1, 4

Hormonal Options

1. Levonorgestrel-releasing intrauterine device (LNG-IUD)

   • Most effective medical treatment for idiopathic AUB
   • Provides contraception with <1% failure rate
   • Significantly reduces menstrual blood loss 1, 3

2. Combined oral contraceptives

   • Effective for regulating menstrual cycles in anovulatory bleeding
   • Can increase estrogen content from 20mcg to 35mcg for better bleeding control
   • Consider decreasing hormone-free interval from seven to four or five days 1, 5

3. Progestin-only options

   • Oral progestins for 21 days per month
   • Injectable contraception (DMPA) with 0.3-6% failure rate
   • Contraceptive implant with 0.05% failure rate 1, 3

4. Selective Progesterone Receptor Modulators (SPRMs)

   • Ulipristal acetate (UPA) can achieve amenorrhea rates up to 90% after multiple treatment courses
   • Particularly effective for fibroid-related bleeding
   • Can reduce fibroid volume by 45-72% 2

Management Algorithm Based on Bleeding Pattern

For Acute Heavy Bleeding

1. Assess for hemodynamic stability
2. If stable:
   • IV conjugated equine estrogen or
   • Multi-dose regimens of combined oral contraceptives or
   • Oral progestins or
   • Tranexamic acid 6
3. If unstable or medical management fails:
   • Consider surgical intervention 6

For Chronic Anovulatory Bleeding

1. Rule out underlying causes:
   • Polycystic ovary syndrome
   • Thyroid dysfunction
   • Hyperprolactinemia 7
2. Treatment:
   • Combined oral contraceptives or progestins to regulate cycles
   • Consider endometrial biopsy for women ≥35 years with recurrent anovulation 7

For Ovulatory Abnormal Bleeding (Menorrhagia)

1. Rule out:
   • Thyroid dysfunction
   • Coagulation defects (especially von Willebrand disease)
   • Structural causes (polyps, fibroids) 7
2. Treatment options:
   • LNG-IUD (most effective)
   • Oral progestins for 21 days/month
   • NSAIDs
   • Tranexamic acid 7

Surgical Management Options

Consider surgical management when:

• Patient is hemodynamically unstable
• Medical management has failed
• Specific structural abnormalities are identified 6

Surgical Options

1. Conservative procedures:

   • Endometrial ablation techniques (thermal balloon, microwave, radiofrequency)
   • Polypectomy or fibroidectomy for structural causes
   • Uterine artery embolization (UAE) for fibroids 2, 3

2. Definitive treatment:

   • Hysterectomy - should not be first-line for idiopathic AUB
   • If performed, vaginal or laparoscopic approaches are preferred 3

Special Considerations

For Fibroid-Related Bleeding

• UAE compared with hysterectomy shows:
  • Similar long-term quality-of-life outcomes
  • Shorter hospital stay and decreased blood loss with UAE
  • Higher reintervention rates with UAE 2

For Patients Using Hormonal Contraception

• Counsel about potential for abnormal bleeding at initiation
• For LNG-IUD users with bleeding:
  • Ensure correct placement
  • Try NSAIDs first, then consider estradiol if ineffective 5
• For combined hormonal contraception users:
  • Increase estrogen content or decrease hormone-free interval
  • Consider low-dose doxycycline 5

Monitoring and Follow-up

• Regular follow-up within 4-6 weeks if bleeding persists despite treatment
• Monitor hemoglobin/hematocrit if heavy bleeding continues
• Transition to long-term maintenance therapy once acute bleeding is controlled 1, 6

Pitfalls and Caveats

• Always rule out pregnancy before initiating treatment
• Consider endometrial biopsy in women ≥35 years with recurrent anovulation
• Morcellation in minimally invasive procedures increases risk of spreading occult malignancy
• Chronic use of GnRH agonists results in trabecular bone loss, making them suitable only for temporary use 2
• Always perform speculum examination and Pap smear early to rule out cervical disease 3