What are the treatment options for abnormal vaginal bleeding?

Treatment of Abnormal Vaginal Bleeding

Immediate Assessment and Stabilization

For hemodynamically unstable patients with bleeding saturating a large pad or tampon hourly for at least 4 hours, urgent evaluation and stabilization take priority before diagnostic workup. 1

• Assess hemodynamic stability first: check vital signs, orthostatic changes, and signs of hypovolemia 1
• Obtain IV access and initiate fluid resuscitation if unstable 2
• All reproductive-age women must have a pregnancy test (β-hCG) performed immediately to exclude pregnancy-related bleeding 1, 3

Diagnostic Workup

Combined transvaginal and transabdominal ultrasound with Doppler is the first-line imaging study for all patients with abnormal uterine bleeding. 1

• Transvaginal ultrasound is the primary modality for evaluating endometrium and myometrium 1
• In postmenopausal women, endometrial thickness <4 mm has nearly 100% negative predictive value for cancer 1
• Endometrial thickness ≥4 mm in postmenopausal women requires endometrial biopsy 1
• Office endometrial biopsy can establish diagnosis in most cases, but has a 10% false-negative rate 4
• If office biopsy is negative but symptoms persist, fractional dilation and curettage under anesthesia is mandatory 4

Additional laboratory testing:

• Thyroid-stimulating hormone and prolactin levels 1
• Coagulation studies if clinically indicated 3
• CA-125 if extrauterine disease suspected (though can be falsely elevated with peritoneal inflammation) 4

Medical Treatment Algorithm

First-Line Treatment

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment, reducing menstrual blood loss by 71-95%. 3

• LNG-IUD is particularly effective for perimenopausal women and can be used through menopause 3
• This is superior to all other medical therapies for heavy menstrual bleeding 3

Second-Line Treatment (if LNG-IUD not used or contraindicated)

NSAIDs are the recommended first-line pharmacologic treatment for women not using LNG-IUD. 3

• Dose NSAIDs for 5-7 days during menstruation only 3
• Critical caveat: NSAIDs must be avoided in women with cardiovascular disease due to increased MI and thrombosis risk 1, 3

Third-Line Treatment

Tranexamic acid should be considered if NSAIDs are ineffective, but only in patients without cardiovascular disease. 3

• Tranexamic acid is contraindicated in women with cardiovascular disease due to thrombosis risk 1, 3

Hormonal Options

Progestins can be used for abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology:

• Norethindrone acetate 2.5-10 mg daily for 5-10 days produces secretory transformation of adequately primed endometrium 5
• Progestin withdrawal bleeding typically occurs within 3-7 days after discontinuation 5
• Patients with recurrent episodes may benefit from planned menstrual cycling with progestins 5
• Medroxyprogesterone acetate is an alternative progestin option 6

Important consideration: Combined hormonal contraceptives require careful assessment of cardiovascular and thrombotic risk factors, especially in perimenopausal women 3

Special Populations and Considerations

Patients on Anticoagulation

• Approximately 70% of women on anticoagulation experience heavy menstrual bleeding 1
• Reassess the indication for ongoing antiplatelet therapy and consider discontinuation if appropriate 1
• Review all medications that may contribute to bleeding 3

Postmenopausal Women

Approximately 90% of patients with endometrial carcinoma present with abnormal vaginal bleeding. 4

Risk factors requiring heightened suspicion for endometrial cancer:

• Obesity, diabetes, hypertension 1
• Unopposed estrogen exposure, tamoxifen use 1
• Lynch syndrome or family history of endometrial cancer 1

Patients with Cardiovascular Disease

Both NSAIDs and tranexamic acid are contraindicated in patients with cardiovascular disease. 1, 3

• This creates a treatment challenge requiring alternative approaches
• LNG-IUD becomes even more important as first-line therapy in this population 3

When Medical Management Fails

Referral to gynecology is mandatory for:

• Failed medical management after optimal therapy 1, 3
• Endometrial sampling showing hyperplasia or malignancy 1
• Postmenopausal bleeding with endometrial thickness ≥4 mm 1

Surgical options after failed medical management:

• Endometrial ablation as conservative surgical option 3
• Hysterectomy provides complete resolution and significantly better health-related quality of life compared to other therapies 1

Common Pitfalls to Avoid

• Never assume negative office endometrial biopsy excludes pathology in symptomatic patients - the 10% false-negative rate mandates D&C if symptoms persist 4
• Do not use NSAIDs or tranexamic acid in cardiovascular disease patients - both increase thrombotic risk 1, 3
• Do not delay pregnancy testing in reproductive-age women - pregnancy-related bleeding requires completely different management 1, 3
• Do not overlook Lynch syndrome screening - universal testing of endometrial tumors for DNA mismatch repair defects is recommended 4