What is the initial treatment for abnormal uterine bleeding?

Initial Treatment for Abnormal Uterine Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for abnormal uterine bleeding, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1

Immediate Assessment Required Before Treatment

Before initiating any therapy, three critical steps must be completed:

• Test for pregnancy in all reproductive-age women with abnormal uterine bleeding, as this is a mandatory first step 2
• Assess hemodynamic stability—urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
• Obtain combined transabdominal and transvaginal ultrasound with Doppler as first-line imaging to identify structural causes (polyps, adenomyosis, fibroids, malignancy) 2

Medical Management Algorithm

First-Line Treatment Options (in order of effectiveness):

1. Levonorgestrel-releasing intrauterine device (LNG-IUD):

• Reduces menstrual blood loss by 71-95% 1
• Efficacy equivalent to endometrial ablation 1
• Most effective long-term medical treatment available 3

2. Combined hormonal contraceptives (CHCs):

• Particularly effective for ovulatory dysfunction bleeding 1
• Can be combined with NSAIDs to further reduce bleeding volume 1
• Decrease menstrual flow by approximately 50% 4
• For acute severe bleeding, high-dose estrogen-progestin oral contraceptives can be used 3

3. Oral progestins:

• Administer for 21 days per month for menstrual blood loss reduction 1
• Effective for women with cyclic heavy bleeding related to menstrual cycle 1
• Also effective when given for 10 days each month 5

4. NSAIDs:

• Decrease bleeding by 30-50% 4
• Can be used in combination with hormonal contraceptives 1

5. Tranexamic acid:

• Reduces menstrual blood loss by approximately 50% 4
• Can be given intravenously for severe acute bleeding 3
• FDA-approved for ovulatory bleeding 5

Critical Caveats and Contraindications

• Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to association with MI and thrombosis 2
• In patients on antiplatelet therapy, reassess the indication and consider discontinuation if appropriate 2
• If bleeding persists beyond 3 months on oral contraceptives, consider supplemental estrogen and/or NSAIDs, or switch to a higher estrogen content formulation 6

When Medical Management Fails

• If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is indicated 1
• Hysteroscopy allows visualization of the endometrial cavity and diagnosis of focal lesions possibly missed by endometrial sampling 1
• Endometrial ablation serves as a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Hysterectomy is the definitive treatment when medical management fails or is contraindicated 1, 3

Special Populations

Acute severe bleeding with hemodynamic instability requires:

• Uterine tamponade 3
• Intravenous estrogen 3
• Dilation and curettage 3
• Uterine artery embolization 3

Perimenopausal patients:

• Can be treated with cyclic progestin or cyclic conjugated equine estrogens for 25 days with concomitant medroxyprogesterone acetate for days 18-25 7
• Low-dose combination oral contraceptives are appropriate for nonsmokers without vascular disease 7