What are the medical management options for a 51-year-old female with Abnormal Uterine Bleeding (AUB)?

Medical Management of Abnormal Uterine Bleeding in a 51-Year-Old Woman

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

Initial Diagnostic Workup Required

Before initiating treatment, this 51-year-old woman requires specific evaluation:

• Pregnancy test (β-hCG) must be performed even in perimenopausal women to rule out pregnancy-related bleeding 2
• Transvaginal ultrasound with Doppler is the first-line imaging study to identify structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 2
• Endometrial assessment is critical at this age: if postmenopausal or perimenopausal with risk factors (obesity, diabetes, hypertension, unopposed estrogen exposure), endometrial sampling should be strongly considered 2
• TSH and prolactin levels should be checked to exclude thyroid dysfunction and hyperprolactinemia 2
• Complete blood count to assess for anemia from chronic blood loss 3

Medical Management Algorithm

First-Line Treatment: Levonorgestrel-Releasing IUD

The LNG-IUD should be offered as the primary medical therapy, demonstrating:

• 71-95% reduction in menstrual blood loss 1
• Efficacy equivalent to endometrial ablation 1
• Superior effectiveness compared to all other medical options 4, 5
• Minimal systemic absorption, making it safer for women with cardiovascular risk factors 1

Second-Line Options (If LNG-IUD Contraindicated or Declined)

Tranexamic acid is the next most effective option:

• Reduces menstrual blood loss by 26-60% 4
• Dose: 3.9-4 grams daily for 4-5 days starting from day 1 of menstruation 4
• Critical caveat: Avoid in women with cardiovascular disease due to thrombosis risk 2, 1
• Contraindicated in active thromboembolic disease or history of thrombosis 4

Combined hormonal contraceptives (CHCs):

• Reduce menstrual flow by approximately 50% 6
• Effective for ovulatory dysfunction bleeding 1
• Can be combined with NSAIDs for additional bleeding reduction 1
• Important consideration: At age 51, assess cardiovascular risk factors, smoking status, and hypertension before prescribing 1

Oral progestins (cyclic):

• Administer for 21 days per month 1, 5
• Effective for cyclic heavy bleeding related to anovulation 1
• Safer option for women with cardiovascular contraindications to estrogen 1

NSAIDs (adjunctive therapy):

• Reduce menstrual blood loss by 30-50% 6
• Can be used in combination with hormonal methods 7
• Avoid in cardiovascular disease due to MI risk 2, 1

Special Considerations for This Age Group

Perimenopausal Context

At 51 years old, this patient is likely perimenopausal, which creates specific considerations:

• Endometrial cancer risk increases with age, making structural evaluation mandatory before medical management 2
• If endometrial thickness ≥4 mm on ultrasound in the setting of irregular bleeding, endometrial sampling is required 2
• Anovulatory cycles are common in perimenopause, leading to unopposed estrogen and increased endometrial cancer risk 5

When to Refer to Gynecology

Immediate referral is indicated for 2:

• Failed medical management after 3-6 months
• Endometrial sampling showing hyperplasia or malignancy
• Endometrial thickness ≥4 mm with persistent bleeding despite treatment
• Structural abnormalities requiring surgical intervention

Common Pitfalls to Avoid

Do not use endometrial biopsy alone to rule out focal lesions—it has variable sensitivity and may miss polyps or focal pathology 1. Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for detecting intracavitary pathology 2.

Do not prescribe NSAIDs or tranexamic acid to women with known cardiovascular disease, hypertension requiring multiple medications, or history of thrombosis 2, 1.

Do not assume bleeding is benign in this age group without proper structural evaluation—endometrial cancer must be excluded 2.

Surgical Options If Medical Management Fails

If bleeding persists despite optimal medical therapy:

• Endometrial ablation is less invasive than hysterectomy with comparable efficacy to LNG-IUD 1
• Hysterectomy is definitive treatment when medical management fails or is contraindicated, particularly appropriate for women who have completed childbearing 1, 5
• Hysteroscopy allows visualization of the endometrial cavity to diagnose focal lesions potentially missed by sampling 1

Important caveat: Endometrial ablation has long-term complications including postablation Asherman syndrome, cervical stenosis, and potential delayed diagnosis of endometrial cancer 1. Thorough informed consent is essential.