What are the management options for uterine bleeding?

Management of Uterine Bleeding

For general abnormal uterine bleeding in premenopausal women, the levonorgestrel-releasing intrauterine system (20 μg/d) is the most effective first-line medical therapy, achieving 71-95% reduction in menstrual blood loss. 1

Initial Assessment and Urgent Evaluation

• Test for pregnancy immediately in all reproductive-age women with abnormal uterine bleeding 1
• Urgent evaluation is warranted if bleeding saturates a large pad or tampon hourly for at least 4 hours, or if hemodynamic instability is present 1
• Obtain complete blood count to assess for anemia 2, 3
• Consider endometrial biopsy in women ≥35 years with recurrent anovulation, women <35 years with endometrial cancer risk factors, or those with bleeding unresponsive to medical therapy 2
• Evaluate for coagulation disorders (particularly von Willebrand disease, present in ~1% of the population) in women with heavy menstrual bleeding since menarche 2, 4

Medical Management by Clinical Scenario

Heavy Menstrual Bleeding (First-Line Options)

The levonorgestrel 20 μg/d intrauterine device is the single most effective medical treatment, comparable to endometrial ablation efficacy 1. This works primarily at the endometrial level with minimal systemic absorption 1.

Alternative first-line options include:

• Combined oral contraceptives for women requiring contraception 2, 5
• Tranexamic acid 1 g orally during menses (FDA-approved for ovulatory bleeding) 2, 5, 3
• Continuous oral progestins (medroxyprogesterone acetate 10 mg daily for 10-21 days per month) 2, 4, 5
• NSAIDs (can be combined with hormonal methods to decrease bleeding) 2, 5

Acute Heavy Bleeding Episodes

• High-dose estrogen is the best option for acute bleeding control 4
• Multidose combined oral contraceptive regimen (multiple pills per day) 5
• Multidose progestin-only regimen 5
• Tranexamic acid 1 g IV over 10 minutes 6
• Curettage is indicated for acute bleeding causing hypovolemia or when endometrial cancer risk factors are present 4

Anovulatory Bleeding (Chronic Management)

• Adolescents: Medroxyprogesterone acetate 10 mg orally daily for 10 days each month for ≥3 months, then monitor 4
• Reproductive age women needing contraception: Combined oral contraceptives 2, 4
• Reproductive age women desiring pregnancy: Clomiphene citrate 4
• Perimenopausal women: Cyclic progestin or cyclic conjugated estrogens for 25 days with medroxyprogesterone acetate days 18-25 4
• Low-dose combination oral contraceptives may be used in perimenopausal nonsmokers without vascular disease 4

Special Populations

Women on anticoagulation therapy:

• Progestin-only methods are preferred 5
• GnRH agonists may be considered 5
• Avoid NSAIDs and tranexamic acid due to thrombosis risk 1

Women with inherited bleeding disorders:

• All hormonal methods can be used 5
• Tranexamic acid is effective 5
• Desmopressin acetate nasal spray for von Willebrand disease 4

Women with cardiovascular disease or post-SCAD:

• Levonorgestrel IUD is strongly preferred over systemic hormones 1
• Avoid NSAIDs and tranexamic acid (associated with MI and thrombosis) 1
• If systemic hormones are necessary, use transdermal agents to minimize thrombotic factor activation 1
• Cyclic oral progestin reduces bleeding by 87% but has theoretical safety concerns 1
• Consider endometrial ablation techniques (thermal balloon, microwave, radiofrequency) as they avoid systemic hormones and reduce pregnancy risk 1

Postpartum Hemorrhage Management

Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of birth for postpartum hemorrhage, as delay reduces benefit by 10% for every 15 minutes 6.

• Give oxytocin 5-10 IU slow IV or IM immediately 6
• Implement uterine massage and bimanual compression 6
• Administer second dose of tranexamic acid 1 g if bleeding continues after 30 minutes or restarts within 24 hours 6
• Initiate massive transfusion protocol if blood loss exceeds 1500 mL 6
• Consider intrauterine balloon tamponade if pharmacological management fails 6

Surgical Options When Medical Management Fails

For women no longer desiring fertility or when medical therapy is ineffective:

• Endometrial ablation (second-generation techniques: thermal balloon, microwave, radiofrequency) 1
• Hysteroscopic myomectomy for submucosal fibroids 1
• Hysterectomy as definitive treatment 2, 3
• Uterine artery embolization for fibroids 1, 6

Critical Pitfalls to Avoid

• Do not use medroxyprogesterone acetate injection for dysfunctional uterine bleeding due to prolonged action and unpredictable withdrawal bleeding timing 7
• Methylergonovine is contraindicated in hypertensive patients 6
• Delaying tranexamic acid administration in postpartum hemorrhage significantly reduces effectiveness 6
• Failing to test for pregnancy can lead to misdiagnosis and inappropriate treatment 1
• Missing von Willebrand disease diagnosis (affects 1% of population) leads to ineffective treatment 2, 4
• Using NSAIDs or tranexamic acid in women with cardiovascular disease increases MI and thrombosis risk 1