Management of Abnormal Uterine Bleeding
For abnormal uterine bleeding, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1, 2
Initial Diagnostic Framework
Before initiating treatment, use the PALM-COEIN classification system to categorize the bleeding cause: 3, 1
Structural causes (PALM):
Non-structural causes (COEIN):
Essential Workup Elements
Laboratory evaluation must include: 3, 1
- Pregnancy test (beta-hCG)
- Thyroid-stimulating hormone
- Prolactin levels
- Transvaginal ultrasound (first-line for reproductive-age women)
- Saline infusion sonohysterography (96-100% sensitivity for intracavitary lesions) 3
Endometrial sampling is mandatory for: 1
- Women ≥35 years with recurrent anovulation 4
- Women <35 years with endometrial cancer risk factors 4
- Any woman with persistent bleeding unresponsive to medical therapy 4
Critical pitfall: Endometrial biopsy is preferred over dilation and curettage due to lower invasiveness, better safety profile, and lower cost, though sensitivity varies with lesion type and distribution. 3
Medical Management Algorithm
First-Line Treatment: Levonorgestrel-Releasing IUD
The LNG-IUD (20 μg/day) should be the initial treatment for most women with AUB, particularly those with ovulatory dysfunction or heavy menstrual bleeding. 1, 2 This device demonstrates:
- 71-95% reduction in menstrual blood loss 1, 2
- Efficacy equivalent to endometrial ablation 2
- Superior results compared to oral progesterone therapy for fibroid-related bleeding 2
Special advantage: For women on antiplatelet therapy who develop AUB, the LNG-IUD is particularly effective. 2
Second-Line Hormonal Options
Combined hormonal contraceptives (CHCs): 3, 1
- Effective for ovulatory dysfunction bleeding 3
- NSAIDs can be added to reduce bleeding volume further 1, 4
- Consider increasing estrogen content from 20 mcg to 35 mcg daily if breakthrough bleeding occurs 5
- Administer for 21 days per month for menstrual blood loss reduction 2, 4
- Effective for women with cyclic heavy bleeding related to menstrual cycle 2
- Less effective than LNG-IUD for fibroid-related bleeding 2
Progestin-only contraceptives: 3
- Depot medroxyprogesterone acetate
- Subdermal implants (note: may cause irregular bleeding, especially first year) 2
Non-Hormonal Medical Options
- Non-hormonal alternative for reducing bleeding symptoms
- Particularly useful in patients with fibroids 1
- FDA-approved for ovulatory bleeding 4
- Can be combined with hormonal methods 6
- Effective for both unscheduled spotting and heavy bleeding 2
- Treatment duration: 5-7 days 2
- Can be used adjunctively with hormonal therapies 6, 4
GnRH agonists/antagonists (elagolix, linzagolix, relugolix): 1
- Effectively reduce bleeding symptoms 1
- Significantly reduce fibroid volume when present 1
- Create temporary medical menopause; symptoms return after discontinuation 1
- Indicated for preoperative preparation in leiomyoma patients 6
Surgical Management
When medical treatment fails, is contraindicated, or not tolerated, surgical intervention becomes appropriate. 3
Surgical Options in Order of Invasiveness
- Less invasive alternative to hysterectomy
- Efficacy comparable to LNG-IUD 2
Hysterectomy (definitive treatment): 1
- Most appropriate when: Medical management fails or is contraindicated, particularly in postmenopausal women with symptomatic fibroids 1
- Provides complete resolution of fibroid-related symptoms 1
- Eliminates recurrence risk 1
- Choose least invasive surgical route based on uterine size and surgical expertise 1
- Studies demonstrate significantly better health-related quality-of-life compared to other therapies 1
Important consideration: Hysterectomy accounts for three-quarters of fibroid treatment in the United States. 1 While definitive, it carries surgical risks that must be weighed against benefits. 1
Uterine artery embolization (UAE): 1
- Meta-analysis shows significantly greater short-term benefits versus hysterectomy 1
- Higher percentage of long-term reintervention required 1
Targeted procedures: 4
- Polypectomy for identified polyps
- Fibroidectomy for submucosal fibroids
Special Clinical Scenarios
Acute Heavy Bleeding
For acute AUB with normal uterus, viable options include: 6
- Parenteral estrogen
- Multidose combined oral contraceptive regimen
- Multidose progestin-only regimen
- Tranexamic acid
Inherited Bleeding Disorders
All hormonal methods and tranexamic acid can be used effectively. 6
Women on Anticoagulation Therapy
Preferred treatments: 6
- Progestin-only methods
- GnRH agonists
Adenomyosis
This condition frequently coexists with fibroids and presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia, commonly affecting women in their 40s and contributing significantly to menorrhagia and anemia. 1 Treatment follows the same algorithm, with hysterectomy as definitive management.
Management of Treatment Failure
If bleeding persists despite initial medical therapy: 3, 2
- Further investigation with imaging or hysteroscopy is indicated 3
- Hysteroscopy allows visualization of endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 3
- Evaluate for underlying conditions: fibroids, polyps, endometrial hyperplasia 2
- Consider second course of progesterone after appropriate evaluation 2
- If unacceptable to patient, offer alternative contraceptive methods 2
Critical Decision-Making Factors
Patient age and fertility desires are critical in treatment selection. 1 The algorithm prioritizes:
- Medical management first (LNG-IUD preferred) 1
- Less invasive procedures if medical management fails
- Hysterectomy as definitive option when other treatments unsuccessful or contraindicated 1
Key caveat: When transvaginal ultrasound cannot completely evaluate the endometrium, MRI or endometrial sampling should be considered. 1