What are the hormonal and medical methods to reduce excessive uterine bleeding?

Hormonal and Medical Methods to Reduce Excessive Uterine Bleeding

For excessive uterine bleeding, first-line treatments include combined hormonal contraceptives and progestin-only methods, while second-line options include GnRH agonists/antagonists and tranexamic acid, with intravenous conjugated estrogens reserved for acute severe bleeding episodes. 1, 2

First-Line Hormonal Options

Combined Hormonal Contraceptives

• Highly effective for reducing menstrual bleeding (40-50% reduction) 3
• Act by suppressing gonadotropins, inhibiting ovulation, and thinning the endometrium 4
• Available as:
  • Oral contraceptive pills
  • Vaginal rings
  • Transdermal patches
• Contraindicated in women >35 who smoke, history of VTE, stroke, or cardiovascular disease 2

Progestin-Only Methods

1. Levonorgestrel-releasing IUD (LNG-IUD)

   • Most effective medical treatment for menorrhagia (up to 97% reduction in bleeding by 6 months) 2
   • Approximately 50% of users experience amenorrhea or oligomenorrhea by 2 years 2
   • Provides contraception while treating bleeding
   • Local hormone delivery minimizes systemic side effects

2. Progestin-only pills (POPs)

   • Typical failure rate of 5-9% for contraception 2
   • Suitable for women with contraindications to estrogen 2
   • Can be used for cyclic therapy (21 days per month) to regulate bleeding 5

3. Injectable progestogens (DMPA)

   • Can produce amenorrhea with long-term use
   • Provides contraception (0.3-6% failure rate) 2
   • Associated with irregular spotting initially and reversible bone loss 3

Second-Line Hormonal Options

GnRH Agonists and Antagonists

• Effectively reduce bleeding and fibroid volume 1
• Available as:
  • Parenteral GnRH agonists (e.g., leuprolide acetate)
  • Oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) 1
• Hypoestrogenic side effects include headaches, hot flushes, hypertension, and bone mineral density loss 1
• Combination treatment with low-dose estrogen and progestin can mitigate side effects 1
• Typically used for short courses or before surgery 1

Progesterone Receptor Modulators

• Ulipristal acetate reduces both bleeding and bulk symptoms 1
• Can be administered intermittently, allowing menstruation during medication breaks 1
• Reports of hepatotoxicity have limited approval in the United States 1

Non-Hormonal Medical Options

Tranexamic Acid

• Antifibrinolytic agent that inhibits plasminogen activator 3
• Reduces menstrual blood loss by 40-60% 3
• Non-hormonal option for women who cannot or prefer not to use hormonal treatments
• FDA-approved for treatment of ovulatory bleeding but expensive 5

NSAIDs

• Reduce bleeding by 25-35% through reduced prostaglandin levels 3
• Also improve dysmenorrhea
• First-line medical management for ovulatory bleeding 5

Emergency Treatment for Acute Severe Bleeding

Intravenous Conjugated Estrogens

• Highly effective for acute bleeding episodes (72% success rate vs. 38% with placebo) 6
• Dosage: 25 mg IV, may repeat in 6-12 hours if necessary 7
• Should be administered slowly to prevent flushing 7
• Compatible with normal saline, dextrose, and invert sugar solutions 7
• Not compatible with protein hydrolysate, ascorbic acid, or acidic solutions 7
• Increased risk of thrombosis 3

Treatment Algorithm Based on Bleeding Pattern

For Anovulatory Bleeding:

1. First-line: Combined hormonal contraceptives or cyclic progestins for 21 days per month 1, 5
2. For women with endometrial hyperplasia without atypia: Cyclic or continuous progestin 5
3. For women with hyperplasia with atypia or adenocarcinoma: Refer to gynecologist or gynecologic oncologist 5

For Ovulatory Bleeding (Menorrhagia):

1. First-line: Levonorgestrel-releasing IUD 5
2. Alternative options:
   • Oral progestins for 21 days per month
   • NSAIDs
   • Tranexamic acid 5

Special Considerations

• Women 35 years or older with recurrent anovulation should undergo endometrial biopsy 5
• Women with excessive bleeding unresponsive to medical therapy should undergo endometrial biopsy 5
• When medical management fails, consider structural interventions:
  • Polypectomy
  • Fibroidectomy
  • Uterine artery embolization
  • Endometrial ablation
  • Hysterectomy (most definitive treatment) 5

Common Pitfalls and Caveats

• Rule out underlying conditions such as STIs, pregnancy, or uterine pathology when evaluating bleeding 2
• Consider iron supplementation if bleeding is heavy or prolonged to prevent anemia 2
• Hormonal contraceptives do not protect against sexually transmitted infections 2
• Cessation of GnRH agonist/antagonist therapy leads to rapid recurrence of symptoms 1
• Consider von Willebrand disease in patients with excessive menstrual bleeding unresponsive to standard treatments 8