What are the treatment options for abnormal uterine bleeding?

Treatment of 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

Initial Diagnostic Classification

Before initiating treatment, classify the bleeding using the PALM-COEIN system to identify the underlying cause 2, 1:

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

Essential diagnostic workup includes pregnancy testing (β-hCG), thyroid-stimulating hormone, and prolactin levels 3. Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study 3.

Medical Management Algorithm

First-Line Treatment Options

For ovulatory dysfunction bleeding:

• Combined hormonal contraceptives (CHCs) are effective and can be combined with NSAIDs to further reduce bleeding volume 1
• Progestin-only contraception is an alternative when estrogen is contraindicated 2

For heavy menstrual bleeding (regardless of cause):

• LNG-IUD remains the gold standard, demonstrating efficacy equivalent to endometrial ablation 1
• Oral progestins administered for 21 days per month effectively reduce menstrual blood loss in women with cyclic heavy bleeding 1

Acute Severe Bleeding Management

For hemodynamically unstable patients with bleeding saturating a large pad hourly for at least 4 hours 3:

• Intravenous estrogen for emergency stabilization 4
• High-dose estrogen-progestin oral contraceptives 4
• Intravenous tranexamic acid 4
• Uterine tamponade or dilation and curettage if medical management fails 4

Additional Medical Options

• Oral tranexamic acid is FDA-approved for ovulatory bleeding but is expensive 5
• NSAIDs reduce bleeding volume but should be avoided in patients with cardiovascular disease due to MI and thrombosis risk 3
• Depot medroxyprogesterone for long-term management 4

Surgical Management

When to Consider Surgery

Surgery is indicated when 2:

• Medical treatment fails, is contraindicated, or not tolerated
• Concomitant significant intracavitary lesions are present
• Endometrial sampling shows hyperplasia or malignancy
• Patient preference after informed consent

Surgical Options

Endometrial ablation:

• Less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Important caveat: Potential long-term complications include postablation Asherman syndrome, synechiae, cervical stenosis, endometrial distortion, and delayed endometrial cancer diagnosis 2

Hysterectomy:

• Definitive treatment providing complete symptom resolution and significantly better health-related quality of life compared to other therapies 3
• Most appropriate when medical management fails or is contraindicated, particularly in postmenopausal women with symptomatic fibroids 1

Targeted procedures:

• Myomectomy for fibroids when fertility preservation is desired 4
• Polypectomy for endometrial polyps 4
• Uterine artery embolization for select patients with chronic bleeding 4

Management of Treatment Failure

If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is mandatory 2, 1. Hysteroscopy allows visualization of the endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 2.

Special Considerations

Patients on antiplatelet therapy:

• Reassess the indication for ongoing antiplatelet therapy and consider discontinuation if appropriate 3

Patients with cardiovascular disease:

• Avoid NSAIDs and tranexamic acid due to association with MI and thrombosis 3

Referral to gynecology indicated for:

• Failed medical management 3
• Endometrial sampling showing hyperplasia or malignancy 3
• Postmenopausal bleeding with endometrial thickness ≥4 mm 3