What is the initial treatment for abnormal uterine bleeding?

Initial Treatment for Abnormal Uterine Bleeding

The initial medical treatment for abnormal uterine bleeding associated with ovulatory dysfunction is either combined hormonal contraception or progestin-only contraception, as recommended by ACOG. 1

Immediate Assessment Required

Before initiating treatment, you must first:

• Rule out pregnancy with a β-hCG test in all reproductive-age women 2
• Assess hemodynamic stability - urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 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, 2:

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

First-Line Medical Treatment

For Ovulatory Dysfunction (Most Common)

Primary options 1:

• Combined hormonal contraceptives (oral contraceptive pills)
• Progestin-only contraception (oral or intrauterine)

For Heavy Menstrual Bleeding (Ovulatory Pattern)

The levonorgestrel-releasing intrauterine system (20 μg/day) is the most effective long-term medical treatment, reducing menstrual blood loss by 71-95% 1, 3. This is comparable to endometrial ablation efficacy 1.

Alternative medical options include 3, 4:

• Oral contraceptives (reduce flow by ~50%) 5
• Oral progestins
• Tranexamic acid (reduces flow by ~50%) 5
• NSAIDs (reduce bleeding by 30-50%) 5

Acute Severe Bleeding Management

For hemodynamically unstable patients, high-dose intravenous estrogen is the most effective acute intervention 6, 3. Additional emergency options include 3:

• High-dose estrogen-progestin oral contraceptives
• Oral progestins
• Intravenous tranexamic acid
• Uterine tamponade
• Dilation and curettage

Critical Caveats

Endometrial sampling is mandatory in 3, 4:

• All women ≥45 years old
• Women <45 years with risk factors for endometrial cancer (obesity, PCOS, prolonged unopposed estrogen exposure)
• Any patient with persistent bleeding despite initial treatment

Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to MI and thrombosis risk 1, 2.

If medical treatment fails after 3 months, consider 1:

• Further investigation with hysteroscopy to visualize focal lesions
• Surgical options: endometrial ablation or hysterectomy
• Endometrial ablation is lower-risk than hysterectomy and performs as well as the levonorgestrel IUD 3

Special Population: Adolescents

For adolescents with anovulatory bleeding, oral medroxyprogesterone acetate 10 days per month for ≥3 months is appropriate, with close monitoring thereafter 6.