What are the treatment options for abnormal uterine bleeding?

Treatment Options for Abnormal Uterine Bleeding

The most effective first-line treatment for abnormal uterine bleeding is the levonorgestrel-releasing intrauterine system (LNG-IUS), which provides a 71-95% reduction in menstrual blood loss while offering contraceptive benefits. 1

Classification and Evaluation

Abnormal uterine bleeding should be classified using the PALM-COEIN system:

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

Initial evaluation should include:

• Pregnancy test
• Thyroid function tests and prolactin levels
• Complete blood count to assess for anemia
• Transvaginal ultrasound for structural evaluation
• Endometrial biopsy for women ≥35 years with recurrent anovulation or risk factors 1

Medical Treatment Options

First-Line Treatments

1. Levonorgestrel-releasing intrauterine system (LNG-IUS)

   • Provides 71-95% reduction in menstrual blood loss
   • Mirena (20 μg/day) has the strongest evidence for efficacy
   • Kyleena (14 μg/day) may be less effective for bleeding control 1

2. Combined hormonal contraceptives

   • Effective for reducing menstrual blood loss
   • Can be used in extended or continuous regimens
   • Particularly useful for women who also need contraception 1

3. Tranexamic acid

   • Provides 26-60% reduction in menstrual blood loss
   • Take only during menstruation
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

4. Nonsteroidal anti-inflammatory drugs (NSAIDs)

   • Reduce menstrual blood loss by 25-35%
   • Recommended for short-term treatment (5-7 days) during menstruation
   • May increase cardiovascular risk with long-term use 1, 3

Progestin Options

1. Oral progestins

   • Effective when given for 21 days per month
   • Option when estrogen is contraindicated
   • Less effective than LNG-IUS or combined hormonal contraceptives 2, 1

2. Medroxyprogesterone acetate

   • Can be used for anovulatory bleeding, particularly in adolescents
   • May cause weight gain (average 5.4 lb after 1 year, 16.5 lb after 6 years)
   • May delay return to fertility after discontinuation 4

Treatment Algorithm Based on Bleeding Pattern

For Anovulatory Bleeding:

1. Combined hormonal contraceptives for women who need contraception
2. Cyclic progestins (10 days each month for 3-6 months) for those who don't need contraception
3. For perimenopausal women: cyclic progestin or cyclic estrogen with progestin 2, 5

For Ovulatory Bleeding (Menorrhagia):

1. LNG-IUS (first-line)
2. Combined hormonal contraceptives
3. Tranexamic acid
4. NSAIDs
5. Oral progestins for 21 days per month 1, 5

Surgical Options for Treatment Failure

If medical management fails after 3-6 months of adequate trial, consider:

1. Endometrial ablation

   • Less invasive alternative to hysterectomy
   • Suitable for women with completed childbearing
   • Potential complications include delayed diagnosis of endometrial cancer, endometrial distortion, post-ablation syndrome 1

2. Hysterectomy

   • Definitive treatment for refractory cases
   • Consider when other treatments have failed or when significant intracavitary lesions are present 2, 1

Special Considerations

• Structural abnormalities: If polyps or submucosal fibroids are identified, consider polypectomy, fibroidectomy, or uterine artery embolization 5

• Hyperplasia: Hyperplasia without atypia may be treated with cyclic or continuous progestin; hyperplasia with atypia requires referral to gynecology 5

• Bleeding disorders: Consider screening for von Willebrand disease, which affects approximately 1% of the population and can present as abnormal uterine bleeding 5

• Hormonal contraception users: For those experiencing bleeding while on hormonal contraception, treatment depends on the specific method used. For LNG-IUS users, ensure correct placement and consider NSAIDs; for combined hormonal contraception users, consider increasing estrogen content or decreasing hormone-free interval 6