What is the management approach for abnormal uterine bleeding?

Management of Abnormal Uterine Bleeding

Immediate Assessment and Stabilization

Begin with hemodynamic assessment and pregnancy testing in all reproductive-age women, followed by transvaginal ultrasound with Doppler as the definitive first-line imaging study. 1

• Urgent evaluation is required if bleeding saturates a large pad or tampon hourly for at least 4 hours 1
• Perform β-hCG pregnancy test immediately in all reproductive-age women 1
• Order complete blood count with platelets to assess for anemia and thrombocytopenia 2
• Check thyroid-stimulating hormone and prolactin levels as part of initial workup 1
• Combined transabdominal and transvaginal ultrasound with Doppler identifies structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1

Diagnostic Classification Using PALM-COEIN

The PALM-COEIN system separates structural from non-structural causes 1, 3:

Structural causes (PALM):

• Polyp - common in women over 40 years 1
• Adenomyosis - frequent in premenopausal women in their 40s 3
• Leiomyoma - most common structural cause under age 40 1
• Malignancy/hyperplasia - primary concern in postmenopausal bleeding 1

Non-structural causes (COEIN):

• Coagulopathy - von Willebrand disease most common, present in ~1% of population 4
• Ovulatory dysfunction - polycystic ovary syndrome, thyroid dysfunction, hyperprolactinemia 5
• Endometrial - molecular deficiencies in endometrial hemostasis 1
• Iatrogenic - anticoagulation (70% experience heavy bleeding), hormonal contraceptives, IUDs 1
• Not yet classified 3

Endometrial Sampling Indications

Perform endometrial biopsy in these specific populations 5:

• Women ≥35 years with recurrent anovulation
• Women <35 years with risk factors for endometrial cancer
• Any woman with excessive bleeding unresponsive to medical therapy

First-Line Medical Management Algorithm

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 3

Medical Treatment Hierarchy:

For ovulatory dysfunction bleeding:

• Combined hormonal contraceptives (CHCs) are effective and can be combined with NSAIDs for additional bleeding reduction 3
• Oral medroxyprogesterone acetate 10 days per month for ≥3 months in adolescents 4
• Cyclic progestin for 21 days per month reduces menstrual blood loss in women with cyclic heavy bleeding 3

For ovulatory heavy menstrual bleeding (menorrhagia):

• LNG-IUD as first-line 3
• Tranexamic acid (FDA-approved but expensive) 5
• NSAIDs reduce menstrual blood loss 5
• Oral contraceptives for those requiring contraception 4

For perimenopausal women:

• Cyclic progestin therapy 4
• Cyclic conjugated equine estrogens for 25 days with medroxyprogesterone acetate days 18-25 4
• Low-dose combination oral contraceptives in nonsmokers without vascular disease 4

Critical Caveat for Cardiovascular Disease Patients:

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

• In women on antiplatelet therapy, reassess indication and discontinue if appropriate 1
• Hormonal therapy is relatively contraindicated after spontaneous coronary artery dissection 6
• LNG-IUD may be considered as it acts primarily at endometrial level with minimal systemic absorption 6

Surgical Management

Endometrial ablation serves as a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD. 3

Surgical Options by Indication:

• Polypectomy/fibroidectomy: When clear structural lesions identified 5
• Endometrial ablation: Second-generation techniques (thermal balloon, microwave, radiofrequency) for women who have completed childbearing 6
• Uterine artery embolization: Alternative for fibroid-related bleeding 5
• Hysterectomy: Most definitive treatment when medical management fails or is contraindicated, particularly in postmenopausal women with symptomatic fibroids 3, 5

Management of Treatment Failure

If bleeding persists despite initial medical therapy 3:

• Perform hysteroscopy to visualize endometrial cavity and endocervix
• Hysteroscopy diagnoses focal lesions potentially missed by endometrial sampling
• Consider combination therapy with two or more medical agents 4
• Proceed to surgical options if medical management exhausted

Special Clinical Scenarios

For acute bleeding with hypovolemia:

• High-dose estrogen controls acute episodes most effectively 4
• Curettage indicated for hypovolemic patients 4
• High-dose oral or injectable progestin-only medications for short-term hemodynamically unstable patients 6

For von Willebrand disease:

• High-concentration desmopressin acetate nasal spray available without hepatitis/HIV transmission risk 4
• This disorder is present in approximately 1% of the population and commonly misdiagnosed as dysfunctional uterine bleeding 4

For hyperplasia findings:

• Hyperplasia without atypia: treat with cyclic or continuous progestin 5
• Hyperplasia with atypia: refer to gynecologist 5
• Adenocarcinoma: refer to gynecologic oncologist 5