From the Guidelines
The treatment for a 42-year-old with abnormal uterine bleeding (AUB) should begin with hormonal therapy, specifically combined hormonal contraceptives or a levonorgestrel intrauterine device (Mirena), as recommended by the most recent guidelines 1.
Key Considerations
- The choice of treatment should be guided by the patient's desire for future fertility, the severity of symptoms, and any contraindications to specific therapies.
- Evaluation should include ruling out pregnancy, thyroid dysfunction, and structural abnormalities like fibroids or polyps through appropriate testing before finalizing treatment.
- If hormonal treatments fail or are contraindicated, surgical options like endometrial ablation or hysterectomy might be considered.
Treatment Options
- Combined hormonal contraceptives (like ethinyl estradiol 20-35 mcg with progestin)
- Levonorgestrel intrauterine device (Mirena)
- Tranexamic acid (1000 mg three times daily during heavy bleeding days)
- Nonsteroidal anti-inflammatory drugs like ibuprofen (600 mg every 6 hours during menses)
Recent Guidelines
The 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1 provide guidance on managing bleeding irregularities, including spotting, light bleeding, or heavy or prolonged bleeding, and recommend considering the patient's goals, exploring underlying health conditions, and offering treatment options based on patient preferences and medical history.
Underlying Causes
AUB can be caused by structural or nonstructural etiologies, including polyps, adenomyosis, leiomyoma, malignancy, coagulopathies, ovulatory dysfunction, and iatrogenic causes 1.
Patient-Centered Approach
The treatment approach should be patient-centered, taking into account the patient's preferences, treatment goals, and medical history, as emphasized in the 2024 guidelines 1.
From the Research
Treatment Options for Abnormal Uterine Bleeding (AUB)
The treatment for a 42-year-old woman with AUB can be medical and/or surgical, depending on the cause 2. The key factors to consider before initiating treatment are age, desire for future pregnancy, and etiology of AUB.
Medical Treatment
Medical treatment for AUB can include:
- Iron supplementation to treat anemia
- Hormonal therapies, such as combined oral contraceptives (COC) and progestin-only pills, which can inhibit the hypothalamic-pituitary-ovarian axis and induce endometrial atrophy 3
- Non-hormonal therapies, such as tranexamic acid, which is a cheap and effective oral anti-fibrinolytic hemostatic agent that can be used to manage excessive menstrual bleeding 4
- Levonorgestrel intrauterine devices (LNG-IUS), which are a first-line treatment for non-organic causes of AUB 3, 5, 6
Surgical Treatment
Surgical treatment options for AUB include:
- Removal of a focal lesion
- Endometrial resection or destruction
- Hysterectomy, which is the definitive treatment for AUB when alternative treatments fail 2, 5, 6
- Endometrial ablation, which is a less invasive and safe alternative to hysterectomy in women with AUB 5
Considerations
When choosing a treatment option, it is essential to consider the patient's age, desire for future pregnancy, and the etiology of AUB. The PALM-COIEN classification system can be used to classify the etiologies of AUB and guide treatment decisions 2, 6. Additionally, treatment efficiency can be assessed using the same tools as pretherapeutic evaluation, and improvement of quality of life has become the main goal for most international guidelines addressing AUB 2.