What are the treatment options for Abnormal Uterine Bleeding (AUB)?

Treatment of Abnormal Uterine Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for AUB, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1

Initial Assessment and Stabilization

Assess hemodynamic stability immediately by measuring orthostatic blood pressure and pulse. 2 Urgent evaluation is warranted if bleeding saturates a large pad or tampon hourly for ≥4 hours. 3, 2

Essential Diagnostic Steps:

• Pregnancy test (β-hCG) in all reproductive-age women, regardless of sexual history 3, 1, 2
• Combined transabdominal and transvaginal ultrasound with Doppler as first-line imaging to identify structural causes (polyps, adenomyosis, leiomyomas, malignancy) 3, 1
• Thyroid-stimulating hormone and prolactin levels to exclude endocrine causes 3, 2
• Complete blood count to assess for anemia 4

Medical Management Algorithm

First-Line Treatment (Non-Acute):

Levonorgestrel-releasing IUD (20 μg/day) is the most effective option, reducing menstrual blood loss by 71-95% and providing contraception. 5, 1 This is the only progestin IUD evaluated specifically for AUB treatment. 5

Alternative First-Line Options:

• Combined oral contraceptives (COCs): Effective for ovulatory dysfunction bleeding; can be combined with NSAIDs for additional bleeding reduction 1, 6
• Tranexamic acid: 1300 mg orally three times daily during menses; reduces bleeding by inhibiting fibrinolysis 2, 6, 4
• Oral progestins: Medroxyprogesterone acetate for 21 days per month for cyclic heavy bleeding 1, 7
• NSAIDs (ibuprofen, naproxen): Reduce bleeding by 20-50% in ovulatory menorrhagia 2, 4

Acute Heavy Bleeding Management:

For hemodynamically stable patients:

• High-dose combined oral contraceptives: Monophasic pill containing 30-35 μg ethinyl estradiol, taken three times daily until bleeding stops (usually 24-48 hours), then taper 2, 6
• Tranexamic acid: 1300 mg orally three times daily or IV form for rapid hemostasis 2

For hemodynamically unstable patients:

• Intravenous conjugated estrogen: 25 mg every 4-6 hours (maximum 4 doses) until bleeding slows 2, 7
• High-dose oral progestin regimen as alternative 6

Surgical Management

Endometrial ablation (second-generation techniques: thermal balloon, microwave, radiofrequency) should be considered when medical management fails, offering efficacy comparable to LNG-IUD with long-term effectiveness superior to oral medical treatment. 1, 4

Hysterectomy is the definitive treatment when:

• Medical management fails or is contraindicated 1
• Patient has completed childbearing and desires permanent resolution 5
• Endometrial sampling shows hyperplasia or malignancy 3

Hysterectomy provides complete symptom resolution and significantly better health-related quality of life compared to other therapies. 3 When performed for functional bleeding, vaginal or laparoscopic routes are preferred. 4

Critical Caveats and Special Populations

Cardiovascular Disease/Post-SCAD Patients:

Avoid NSAIDs and tranexamic acid due to MI and thrombosis risk. 5, 1 The levonorgestrel-releasing IUD becomes the preferred option in this population. 5, 1

Patients on Antiplatelet Therapy:

Reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating AUB treatment. 5, 3 Progestin-eluting IUDs are preferred as they work primarily at the endometrial level with minimal systemic absorption. 5

Adolescents:

Anovulation from hypothalamic-pituitary-ovarian axis immaturity is the most common cause. 8 Treatment follows the same algorithm as adults, with high-dose COCs as first-line for acute bleeding. 2

When to Refer to Gynecology

Immediate referral is indicated for: 3, 1, 2

• Failed medical management after 3-6 months of appropriate therapy
• Endometrial sampling showing hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm on ultrasound
• Structural abnormalities requiring surgical intervention

Advanced Diagnostic Considerations

If bleeding persists despite initial therapy:

• Saline infusion sonohysterography: 96-100% sensitivity for uterine pathology; distinguishes leiomyomas from polyps with 97% accuracy 3, 1
• Hysteroscopy with biopsy: Reference method for definitive diagnosis; visualizes focal lesions potentially missed by endometrial sampling 1, 9
• MRI pelvis: When ultrasound incompletely visualizes the uterus or findings are indeterminate 3, 2

Common Pitfalls to Avoid

Do not rely on endometrial biopsy alone to rule out focal lesions, as it has variable sensitivity. 1 Saline infusion sonohysterography has superior sensitivity and negative predictive value for intracavitary pathology. 1

Endometrial ablation complications include postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis—thorough informed consent is essential. 1

Hormonal therapy is relatively contraindicated in SCAD patients despite being first-line for most AUB cases. 5 Careful clinical judgment and consideration of progestin-only IUDs is required. 5