What is the treatment 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 Assessment and Classification

Before initiating treatment, categorize the bleeding using the PALM-COEIN system to identify structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) versus non-structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified). 1, 2

Critical initial steps:

• Perform pregnancy testing in all reproductive-age women 3
• Obtain complete blood count to assess for anemia 2
• Perform endometrial sampling in women ≥45 years old or younger women with unopposed estrogen exposure 2
• Order transvaginal ultrasonography if structural etiology suspected or symptoms persist despite treatment 3, 2

Medical Management Algorithm

First-Line Treatment

Levonorgestrel-releasing IUD (20 μg/day) is the gold standard, providing 71-95% reduction in menstrual blood loss with efficacy equivalent to endometrial ablation, working primarily at the endometrial level with minimal systemic absorption. 3, 1, 2

Alternative Medical Options (in order of preference):

For ovulatory dysfunction bleeding:

• Combined hormonal contraceptives (CHCs) are highly effective and can be combined with NSAIDs for additional bleeding reduction 1, 2
• Oral progestins administered for 21 days per month effectively reduce menstrual blood loss in women with cyclic heavy bleeding 1, 4

For acute severe bleeding with hemodynamic stability:

• High-dose estrogen-progestin oral contraceptives 2, 5
• Oral or parenteral estrogen 2, 5
• Intravenous tranexamic acid 2, 5
• Oral progestins in multidose regimens 5

Additional long-term options:

• Oral tranexamic acid (FDA-approved for ovulatory bleeding, though expensive) 4, 5
• NSAIDs (reduce bleeding by 20-50% and can be combined with hormonal methods) 4, 5
• Depot medroxyprogesterone acetate 2

Important Caveat for Special Populations

In women with cardiovascular disease or post-SCAD (spontaneous coronary artery dissection), avoid NSAIDs and tranexamic acid due to MI and thrombosis risk; the levonorgestrel-releasing IUD becomes the preferred option as systemic progesterone levels increase only minimally. 3

Emergency Management

For hemodynamically unstable patients or bleeding saturating a large pad/tampon hourly for ≥4 hours:

• Uterine tamponade 2
• Intravenous estrogen 2
• Dilation and curettage 2
• Uterine artery embolization 2

Surgical Management

When Medical Management Fails

If bleeding persists despite medical therapy, proceed with further investigation using hysteroscopy, which visualizes the endometrial cavity and endocervix to diagnose focal lesions potentially missed by endometrial sampling. 3, 1

Surgical options in order of invasiveness:

• Endometrial ablation: Less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1, 2
• Polypectomy or myomectomy for identified structural lesions 2, 4
• Uterine artery embolization for fibroids 2, 4
• Hysterectomy: Definitive treatment when medical management fails or is contraindicated, particularly appropriate for postmenopausal women with symptomatic fibroids 1, 2, 4

Common Pitfalls to Avoid

Do not use endometrial biopsy alone to rule out focal lesions - it has variable sensitivity depending on lesion type, size, and location; saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for assessing intracavitary pathology. 3, 6

Do not perform dilation and curettage for diagnosis - endometrial biopsy is less invasive, safer, and lower cost for diagnosing endometrial hyperplasia or cancer. 3

Recognize that endometrial ablation has long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis; provide thorough informed consent. 3

Treatment Goals Framework

Base treatment decisions on specific therapeutic goals: stopping acute bleeding, preventing future heavy bleeding, providing concurrent contraception if desired, and preventing complications such as anemia. 3, 2