What is the treatment for abnormal uterine bleeding?

Treatment of Abnormal Uterine Bleeding

First-Line Treatment Recommendation

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is the most effective first-line treatment for abnormal uterine bleeding, reducing menstrual blood loss by 71-95% with efficacy matching endometrial ablation. 1, 2

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Essential Pre-Treatment Evaluation

Before initiating any treatment, systematically rule out:

• Pregnancy - Perform beta-hCG testing in all reproductive-age women 1, 2
• Structural pathology - Use the PALM-COEIN classification system to identify polyps, adenomyosis, leiomyomas, or malignancy 1, 2
• Endometrial pathology - Obtain endometrial biopsy in women ≥35 years with recurrent anovulation, women <35 years with endometrial cancer risk factors, or when bleeding is unresponsive to medical therapy 3
• Systemic causes - Check TSH for thyroid disease, prolactin for hyperprolactinemia, and consider coagulopathy screening (especially von Willebrand disease in adolescents with heavy bleeding) 2, 3

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Medical Management Algorithm

For Acute Heavy Bleeding (Hemodynamically Stable)

Option 1: High-dose combined oral contraceptives

• Administer low-dose COCs for 10-20 days to achieve rapid bleeding control 2
• This provides faster hemostasis than other oral options 4

Option 2: Intravenous conjugated estrogens (Premarin IV)

• Give 25 mg IV (preferred) or IM, repeat in 6-12 hours if necessary 5
• IV route produces more rapid response than IM administration 5
• This is FDA-approved specifically for abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 5

Adjunctive therapy:

• Add NSAIDs for 5-7 days to reduce bleeding volume by 30-50% 2, 4, 6
• NSAIDs can be combined with any hormonal method for enhanced efficacy 2

For Chronic Heavy Menstrual Bleeding

First-line: LNG-IUD (20 μg/day)

• Reduces menstrual blood loss by 71-95% 1, 2
• Efficacy equivalent to endometrial ablation without surgical intervention 1, 2
• Superior to all oral treatment options for long-term management 2
• Particularly beneficial for women on antiplatelet or anticoagulation therapy 2

Second-line options when LNG-IUD is contraindicated or declined:

• Oral progestins - Administer for 21 days per month for women with cyclic heavy bleeding related to menstrual cycle 1, 3
• Combined hormonal contraceptives - Effective for ovulatory dysfunction bleeding, reduce flow by approximately 50% 1, 4, 6
• Tranexamic acid - Reduces menstrual blood loss by approximately 50%, FDA-approved for ovulatory bleeding but expensive 3, 6
• NSAIDs alone - Decrease menstrual bleeding by 30-50% when used during menses 2, 6

For Anovulatory Bleeding

• Combined oral contraceptives or cyclic progestins regulate menstrual cycles and prevent endometrial hyperplasia from unopposed estrogen 3
• Address underlying causes: polycystic ovary syndrome, thyroid dysfunction, hyperprolactinemia, diabetes, or medication effects (antipsychotics, antiepileptics) 3

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Surgical Management

When to Consider Surgical Intervention

• Medical management fails after 3-6 months of appropriate therapy 1, 2
• Structural lesions identified (polyps, submucous fibroids) 7, 1
• Patient preference for definitive treatment 7
• Contraindications to medical therapy exist 7

Surgical Options in Order of Invasiveness

Hysteroscopic procedures:

• Polypectomy or myomectomy for focal lesions 7
• Hysteroscopy allows direct visualization and treatment of lesions missed by endometrial sampling 1, 2

Endometrial ablation:

• Less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Important caveat: Long-term complications include postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis - thorough informed consent is mandatory 1

Myomectomy (for fibroids):

• Appropriate when uterine conservation is desired 7
• Recurrence rate ranges from 23-33% via abdominal or laparoscopic approach 7
• Laparoscopic myomectomy has 2% major and 9% minor complication rates 7

Uterine artery embolization (UAE):

• For symptomatic fibroids, UAE shows shorter hospital stay and decreased blood loss compared to hysterectomy 7
• Higher reintervention rates (36%) compared to myomectomy (5%), especially for fibroids >5 cm 7

Hysterectomy:

• Most definitive treatment when medical management fails or is contraindicated 1
• Particularly appropriate for postmenopausal women with symptomatic fibroids 1
• Critical warning: Morcellation in minimally invasive hysterectomy increases risk for abdominopelvic recurrence and lower disease-free survival in women with occult malignancy - morcellation is not recommended 7

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Management of Treatment Failure

• If bleeding persists despite 3 months of medical therapy, further investigation is mandatory 1, 8, 2
• Transvaginal ultrasonography should be ordered if structural etiology is suspected 1, 3
• Saline infusion sonohysterography has high sensitivity and negative predictive value for intracavitary pathology 1, 9
• Hysteroscopy with biopsy remains the reference method for definitive diagnosis of focal lesions 1, 2, 9
• Do not rely on endometrial biopsy alone to rule out focal lesions due to variable sensitivity 1

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Special Clinical Scenarios

Women with Cardiovascular Disease or Post-SCAD

• Avoid NSAIDs and tranexamic acid due to MI and thrombosis risk 1
• LNG-IUD becomes the preferred option in this population 1

Women on Anticoagulation Therapy

• Consider progestin-only methods or GnRH agonists 4
• LNG-IUD is particularly effective, reducing bleeding by 71-95% 2

Women with Inherited Bleeding Disorders

• All hormonal methods and tranexamic acid can be used effectively 4
• Von Willebrand disease is the most common coagulation defect causing menorrhagia 3

Adenomyosis

• Frequently coexists with fibroids 1
• Presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia 1
• Commonly affects women in their 40s 1
• LNG-IUD remains first-line treatment 2

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Common Pitfalls to Avoid

• Irregular bleeding with progestin-only contraceptives occurs in approximately 22% of women and requires only reassurance, not treatment 8
• If irregular bleeding persists beyond 3 months on progestin therapy, treat with NSAIDs for 5-7 days or low-dose COCs for 10-20 days 8
• Before attributing symptoms to hormonal therapy, rule out medication interactions, sexually transmitted diseases, pregnancy, or pathologic uterine conditions 8
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 8, 2
• Subdermal implants may cause irregular bleeding, especially during the first year 2
• Alert pathologists when submitting specimens from patients treated with selective progesterone receptor modulators due to progesterone-associated endometrial changes (PAEC) 2

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Pharmaceutical Treatment for Fibroids (When Applicable)

• GnRH agonists reduce uterine and myoma volume, effective for bleeding and bulk symptoms 7
• Use is limited to temporary situations (e.g., preoperative size reduction) due to trabecular bone loss with chronic use 7
• Once discontinued, fibroids rapidly return to previous volume with symptom recurrence 7
• Oral contraceptives manage bleeding symptoms effectively in women with small fibroids 7