What is the role of Oral Contraceptive Pills (OCPs) and progesterone in managing Abnormal Uterine Bleeding (AUB)?

Role of OCPs and Progesterone in Managing Abnormal Uterine Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is the most effective first-line treatment for abnormal uterine bleeding, reducing menstrual blood loss by 71-95%, with efficacy comparable to endometrial ablation. 1, 2

First-Line Medical Management Algorithm

Levonorgestrel-Releasing IUD (Preferred)

• LNG-IUD 20 μg/day represents the gold standard for AUB management, particularly effective for ovulatory dysfunction bleeding 1
• Reduces menstrual blood loss by 71-95% 1
• Efficacy matches endometrial ablation without surgical intervention 3
• Particularly beneficial for women on antiplatelet therapy who develop AUB 1

Combined Oral Contraceptives (Second-Line)

• COCs reduce menstrual flow by approximately 50% and are effective for both acute bleeding control and chronic management 4, 5
• For acute bleeding episodes: use low-dose COCs for 10-20 days if medically eligible 2
• Mechanism: suppress gonadotropins, inhibit ovulation, alter cervical mucus, and induce endometrial changes 6
• Effective for stopping acute bleeding and regulating intermenstrual bleeding 7, 8

Progestin-Only Options (Alternative)

• Oral progestins (norethindrone acetate) for 21 days per month effectively reduce menstrual blood loss 1
• Continuous oral progestins are highly efficacious for heavy menstrual bleeding 5
• Transform proliferative endometrium into secretory endometrium 9
• Critical caveat: Injectable medroxyprogesterone acetate is NOT recommended for dysfunctional uterine bleeding due to prolonged action and unpredictable withdrawal bleeding 9

Treatment Selection Based on Clinical Scenario

For Acute Heavy Bleeding

• Parenteral estrogen, multidose COC regimen, or multidose progestin-only regimen are all viable options 5
• Low-dose COCs for 10-20 days provide rapid control 2
• NSAIDs for 5-7 days reduce bleeding volume and can be combined with hormonal methods 1, 2, 5

For Chronic Heavy Menstrual Bleeding

• LNG-IUD remains superior to all oral options 1
• If LNG-IUD is contraindicated or declined: COCs or continuous oral progestins 10
• For fibroid-related AUB: LNG-IUD shows superior results to oral progesterone therapy 1

For Women with Bleeding Disorders

• All hormonal methods (COCs, progestin-only methods, LNG-IUD) plus tranexamic acid are effective 5

For Women on Anticoagulation

• Progestin-only methods preferred 5
• LNG-IUD particularly effective, reducing blood loss by 71-95% 1
• GnRH agonists as alternative option 5

Adjunctive Therapy

NSAIDs

• Reduce menstrual bleeding by 30-50% when used alone 4
• Effective for both unscheduled spotting and heavy bleeding 1
• Treatment duration: 5-7 days 1, 2
• Can be combined with any hormonal method for enhanced efficacy 5

Tranexamic Acid

• Decreases menstrual flow by approximately 50% 4
• Can be used with hormonal methods 5

Management of Treatment Failure

If Bleeding Persists After Initial Hormonal Treatment

• Further investigation with imaging or hysteroscopy is mandatory 3
• Hysteroscopy allows visualization of endometrial cavity and can diagnose focal lesions missed by endometrial sampling 3
• Endometrial biopsy preferred over dilation and curettage (less invasive, safer, lower cost) 3
• Consider alternative contraceptive methods with enhanced counseling 2

For Persistent Bleeding Despite Progestin-Only Contraceptives

• A second course of progesterone may be considered after appropriate evaluation for underlying causes 1
• If bleeding remains unacceptable, offer alternative contraceptive methods 1, 2

Critical Contraindications to Progesterone

Absolute contraindications include: 1

• Known or suspected pregnancy
• Current or history of thromboembolism
• Undiagnosed vaginal bleeding
• Liver disease

Essential Pre-Treatment Evaluation

Before initiating any hormonal treatment, rule out: 2

• Pregnancy (beta-hCG test required) 3
• Structural pathology: fibroids, polyps, adenomyosis 3, 1, 2
• Endometrial hyperplasia or malignancy (endometrial biopsy if indicated) 3
• Thyroid disease (TSH measurement) 3
• Hyperprolactinemia (prolactin level) 3
• Coagulopathy 3
• Medication interactions 2
• Sexually transmitted infections 2

Use the PALM-COEIN classification system to systematically identify structural (Polyp, Adenomyosis, Leiomyoma, Malignancy) versus nonstructural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified) causes 3, 1

Common Pitfalls to Avoid

• Do not use injectable medroxyprogesterone acetate for AUB management due to unpredictable withdrawal bleeding 9
• Subdermal implants may themselves cause irregular bleeding, especially during the first year 1
• Bleeding during first 3 months of OCP use is common; counseling and reassurance are adequate during this period 8
• Enhanced counseling about expected bleeding patterns reduces method discontinuation 2
• Always alert pathologists when submitting specimens from patients treated with selective progesterone receptor modulators due to progesterone-associated endometrial changes (PAEC) 3