What are the management options for Abnormal Uterine Bleeding (AUB) in women who have undergone tubectomy (tubal ligation)?

Management of Abnormal Uterine Bleeding After Tubectomy

Women with tubectomy who develop AUB should be managed identically to women without tubal ligation, as the sterilization procedure does not alter the treatment approach—management depends entirely on identifying the underlying cause using the PALM-COEIN classification system and treating accordingly. 1, 2

Initial Evaluation Framework

The evaluation must distinguish between structural and non-structural causes using the PALM-COEIN system 1, 2:

• Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/Hyperplasia 1, 2
• Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 1, 2

Critical Age-Based Endometrial Assessment

Endometrial biopsy is mandatory for all women over 45 years with AUB, regardless of tubectomy status. 1

• For women ≤45 years: Perform endometrial biopsy only if specific risk factors for endometrial cancer are present (obesity, diabetes, chronic anovulation, family history) 1
• Transvaginal ultrasound serves as the initial imaging modality to identify structural causes 3, 2
• Saline infusion sonohysterography provides superior accuracy for detecting endometrial polyps and submucous leiomyomas 2
• Hysteroscopy with biopsy remains the gold standard for definitive diagnosis 2

Medical Management Algorithm

First-Line Medical Therapies

For women not desiring fertility, levonorgestrel-releasing intrauterine devices are the most effective medical option, reducing menstrual blood loss by 65-85%. 4

Additional first-line options based on bleeding pattern:

• NSAIDs: Reduce bleeding by 30-50%, particularly effective for heavy menstrual bleeding 4, 1
• Tranexamic acid: Decreases flow by approximately 50%, especially useful during acute bleeding episodes 4, 1
• Combined oral contraceptives: Reduce menstrual flow by approximately 50% and can stop acute bleeding 4, 1

Second-Line Options

• Progestins (oral or injectable): Effective for ovulatory dysfunction and endometrial causes 1, 2
• Danazol and GnRH analogues: Effective but unsuitable for long-term use due to significant side effects 4, 2

Surgical Management

When Medical Therapy Fails or Structural Lesions Present

Minimally invasive procedures should be considered before hysterectomy in women who have completed childbearing. 4, 2

• Endometrial ablation/resection: Appropriate for select patients with heavy menstrual bleeding without structural pathology 4
• Office-based ablation devices: Newer instruments conform to the endometrial cavity and may eliminate the need for hysteroscopy 4
• Hysteroscopic polypectomy or myomectomy: For confirmed polyps or submucous fibroids 2
• Hysterectomy: Reserved for refractory cases or when malignancy/hyperplasia is present 2

Critical Pitfalls to Avoid

Never assume tubectomy itself is the cause of AUB—this delays proper diagnosis of potentially serious underlying conditions. 1, 2

• Do not skip endometrial sampling in women >45 years, as this is the highest-risk group for endometrial cancer 1
• Recognize that AUB affects 35% or higher of women and significantly impacts quality of life through anemia, anxiety, and depression 1, 5
• Assess for coagulopathies (especially von Willebrand disease), thyroid disorders, and medication effects (corticosteroids, antipsychotics, antiepileptics) as these are frequently overlooked non-structural causes 5
• Patients with acute symptomatic blood loss require urgent evaluation for hemodynamic instability before proceeding with diagnostic workup 1