What is the initial treatment for abnormal uterine bleeding?

Initial Treatment for Abnormal Uterine Bleeding

For abnormal uterine bleeding associated with ovulatory dysfunction, initiate medical treatment with either combined hormonal contraception or progestin-only contraception as first-line therapy. 1

Immediate Assessment Required

Before initiating treatment, you must:

• Rule out pregnancy with β-hCG testing in all reproductive-age women 2
• Assess hemodynamic stability - if bleeding saturates a large pad or tampon hourly for ≥4 hours, this warrants urgent evaluation 2
• Obtain transvaginal and transabdominal ultrasound with Doppler as first-line imaging to identify structural causes (polyps, adenomyosis, leiomyomas, malignancy) 2
• Check TSH and prolactin levels to exclude thyroid dysfunction and hyperprolactinemia 1

Classification Framework

Use the PALM-COEIN system to categorize the bleeding 1:

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

This classification guides whether medical versus surgical management is appropriate 1.

First-Line Medical Treatment

For Ovulatory Dysfunction (Most Common)

Combined hormonal contraceptives or progestin-only contraception are the recommended initial medical treatments 1. These options:

• Regulate menstrual cycles effectively 3
• Reduce menstrual blood loss by approximately 50% 4
• Provide contraception if needed 3

For Acute Heavy Bleeding (Hemodynamically Stable)

If bleeding is severe but the patient is stable, consider:

• High-dose oral estrogen 5
• High-dose estrogen-progestin oral contraceptives 6
• Oral progestins 6
• Intravenous tranexamic acid 6

For Chronic Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (20 μg/day) is the most effective long-term medical treatment, reducing menstrual blood loss by 71-95% 1, 6. This performs comparably to endometrial ablation 6.

Alternative long-term options include:

• Oral contraceptives (reduce flow ~50%) 4
• Oral tranexamic acid (reduces flow ~50%) 4
• NSAIDs (reduce flow 30-50%) 4
• Depot medroxyprogesterone 6

Critical Pitfalls to Avoid

Do not use NSAIDs or tranexamic acid in patients with cardiovascular disease - these are associated with MI and thrombosis risk 1, 2.

Breakthrough bleeding during the first 3 months of oral contraceptive use is common and expected 7. Provide counseling and reassurance during this period 7. Only if bleeding persists beyond 3 months should you consider supplemental estrogen, NSAIDs, or switching to a higher estrogen formulation 7.

Endometrial sampling is mandatory in:

• Women ≥45 years old 6
• Women <45 years with unopposed estrogen exposure history 6
• Women with persistent bleeding despite treatment 1

When Medical Treatment Fails

If medical management fails, is contraindicated, or not tolerated, surgical options include endometrial ablation or hysterectomy 1. Hysterectomy remains the definitive treatment 6, while endometrial ablation is a lower-risk alternative that performs as well as the levonorgestrel IUD 6.

For patients with identified structural lesions (polyps, submucosal fibroids), consider polypectomy, myomectomy, or uterine artery embolization 6, 3.

Special Consideration for Hormonal Contraceptive Users

If abnormal bleeding occurs in women already using hormonal contraception, first assess compliance - pregnancy and OCP misuse are frequent causes 7. If non-functional causes are excluded and bleeding persists, consider switching to a different formulation or adding supplemental estrogen 8, 7.