How should abnormal uterine bleeding (AUB) be managed in individuals with low socioeconomic status?

Management of Abnormal Uterine Bleeding in Low Socioeconomic Status Populations

Combined oral contraceptive pills should be the first-line treatment for abnormal uterine bleeding in patients with low socioeconomic status, as they are cost-effective, widely available, and demonstrate superior outcomes with reduced anemia rates.

Primary Treatment Approach

Hormonal therapy with combined oral contraceptives (COCs) is the optimal initial management strategy, showing significant improvement in treatment outcomes (OR = 2.15, p < 0.001) and reduced anemia prevalence (p = 0.042) 1. This approach is particularly suitable for low socioeconomic populations due to:

• Lower cost compared to surgical interventions 1
• Accessibility through public health programs and generic formulations 1
• Dual benefit of contraception and bleeding control 2

Diagnostic Priorities in Resource-Limited Settings

Focus your evaluation on identifying the most common and treatable causes:

• Screen for ovulatory dysfunction first (31.6% of cases), as it responds best to hormonal treatment (OR = 1.75, p = 0.003) 1
• Assess for anemia immediately using basic hemoglobin testing, as this is the most critical complication affecting quality of life 3
• Check thyroid function and blood glucose when available, as extragenital disorders are frequent causes 3
• Consider coagulopathy screening (particularly von Willebrand disease) in adolescents with heavy bleeding since menarche 3, 2

Risk Stratification Based on Patient Characteristics

Age and BMI significantly predict treatment response and should guide your management intensity 1:

• Younger patients (20-29 years) have better treatment response (OR = 0.95 per year increase, p = 0.015) 1
• Higher BMI decreases treatment success (OR = 1.10 per unit increase, p = 0.005), requiring closer monitoring in overweight/obese patients (64.2% of AUB cases) 1

Alternative Hormonal Options When COCs Are Contraindicated

• Progestogens alone for patients with contraindications to estrogen 2
• Levonorgestrel-releasing intrauterine system (LNG-IUS) provides long-term cost-effectiveness despite higher upfront cost 2

Non-Hormonal Alternatives for Cost-Conscious Management

• NSAIDs (non-steroidal anti-inflammatory drugs) reduce menstrual blood loss and are inexpensive 2
• Tranexamic acid (anti-fibrinolytic) is highly effective for heavy bleeding episodes 2

Critical Pitfall: Leiomyoma Detection

Presence of leiomyoma significantly decreases hormonal treatment success (OR = 0.55, p = 0.007) 1. In low-resource settings:

• Perform pelvic examination to detect large fibroids (16.8% of AUB cases) 1
• Reserve ultrasound for patients failing initial hormonal therapy or those with palpable masses 1
• Early identification prevents prolonged ineffective medical management and delayed referral for surgical options 1

Addressing Psychosocial Impact

Mental health screening is essential, as 50% of AUB patients experience anxiety and depression 3. This is particularly relevant in low socioeconomic populations where:

• Social and physical factors increase healthcare-seeking behavior 3
• Quality of life is significantly decreased despite AUB rarely being life-threatening 3
• Work productivity and daily activities are disrupted 3

When to Escalate Care

Refer for specialist consultation or surgical evaluation when:

• Hormonal therapy fails after 3-6 months of adequate trial 1
• Structural abnormalities are identified (polyps, adenomyosis, leiomyoma, malignancy) requiring intervention 1, 4
• Severe anemia persists despite treatment 3
• Bleeding pattern suggests malignancy in older reproductive-age women 5, 4

Multidisciplinary Considerations

Coordinate with endocrinology and hematology when extragenital causes are suspected, as thyroid disorders, diabetes, and coagulation disorders frequently cause AUB 3. This coordination is cost-effective by treating underlying systemic conditions rather than symptoms alone 3.