What is the initial treatment for abnormal uterine bleeding?

Initial Treatment for Abnormal Uterine Bleeding

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

Essential Pre-Treatment Steps

Before initiating any treatment, you must systematically exclude:

• Pregnancy: Perform beta-hCG testing in all reproductive-age women 1, 2, 3
• Structural pathology: Use the PALM-COEIN classification system to identify polyps, adenomyosis, leiomyomas, or malignancy 1, 2
• Systemic causes: Check thyroid-stimulating hormone, prolactin levels, and coagulopathy (especially von Willebrand disease in adolescents with heavy bleeding) 2, 3

Treatment Algorithm Based on Clinical Presentation

For Acute Heavy Bleeding (Hemodynamically Stable)

• High-dose combined oral contraceptives for 10-20 days achieve rapid bleeding control 2
• Add NSAIDs for 5-7 days to reduce bleeding volume by 30-50% 2
• Important caveat: Avoid NSAIDs and tranexamic acid in women with cardiovascular disease or post-SCAD due to MI and thrombosis risk; use LNG-IUD instead 1, 2, 3

For Chronic Heavy Menstrual Bleeding

• First-line: LNG-IUD reduces menstrual blood loss by 71-95% without surgical intervention 1, 2
• Alternative options if LNG-IUD contraindicated or declined:
  • Combined hormonal contraceptives (CHCs) for ovulatory dysfunction bleeding, can be combined with NSAIDs 1
  • Oral progestins for 21 days per month for cyclic heavy bleeding 1
  • Tranexamic acid (though expensive and contraindicated in cardiovascular disease) 2, 3

Special Population Considerations

• Women on anticoagulation therapy: LNG-IUD is particularly effective, reducing bleeding by 71-95% 2
• Women with cardiovascular disease: LNG-IUD is the preferred option; avoid NSAIDs and tranexamic acid 1, 2, 3
• Women requiring contraception: Combined oral contraceptives are effective for ovulatory dysfunction bleeding 1

When to Escalate Beyond Initial Medical Management

If bleeding persists despite 3 months of appropriate medical therapy, further investigation is mandatory 2:

• Transvaginal ultrasonography to identify structural causes 1, 3
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine pathology 3
• Hysteroscopy with biopsy to diagnose focal lesions potentially missed by endometrial sampling 1, 2

Common Pitfalls to Avoid

• Do not rely on endometrial biopsy alone to rule out focal lesions, as it has variable sensitivity 1
• Do not use oral contraceptives in women with cardiovascular disease when treating abnormal bleeding 1, 2, 3
• Do not delay imaging if structural etiology is suspected or symptoms persist despite initial treatment 1, 3

Surgical Options After Failed Medical Management

Consider surgical intervention when medical management fails after 3-6 months 2:

• Endometrial ablation: Less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1, 2
• Hysterectomy: Most definitive treatment when medical management fails or is contraindicated, particularly in postmenopausal women with symptomatic fibroids 1