What is the initial treatment for dysfunctional uterine bleeding?

Initial Treatment for Dysfunctional Uterine Bleeding

The initial medical treatment for dysfunctional uterine bleeding is either combined hormonal contraceptives or progestin-only therapy, with the levonorgestrel-releasing intrauterine device (LNG-IUD) being the single most effective option when appropriate. 1, 2

Diagnostic Prerequisites Before Treatment

Before initiating any therapy, you must confirm the diagnosis by ruling out:

• Pregnancy via beta-hCG testing in all reproductive-age women 2, 3
• Structural pathology using the PALM-COEIN classification system (polyps, adenomyosis, leiomyomas, malignancy/hyperplasia) 1
• Systemic causes including thyroid disease (TSH), hyperprolactinemia (prolactin level), and coagulopathy 1

The ACOG treatment recommendations assume you have confirmed ovulatory dysfunction as the cause and excluded endometrial and structural pathologies. 1

First-Line Medical Treatment Algorithm

Most Effective Option: Levonorgestrel-Releasing IUD

The LNG-IUD (20 μg/day) is the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 2, 3 This device works primarily at the endometrial level with minimal systemic progesterone absorption. 1

• Backup contraception is needed for 7 days only if inserted more than 7 days after menses starts 2, 4
• Particularly effective in women on anticoagulation therapy 3

Alternative First-Line Options

Combined hormonal contraceptives (CHCs) are effective for ovulatory dysfunction bleeding and represent standard first-line therapy. 1

• For adolescents: Use monophasic pills containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 4
• These decrease menstrual blood loss by inducing regular shedding of a thinner endometrium 4
• Can be combined with NSAIDs for 5-7 days to further reduce bleeding volume 2, 4

Progestin-only contraception is equally recommended by ACOG as first-line therapy. 1

• Oral medroxyprogesterone acetate: 10 days per month for at least 3-6 months 5
• Cyclic oral progestin reduces bleeding by 87% and often results in only light bleeding 1
• Critical caveat: Injectable depot medroxyprogesterone acetate (DMPA) is NOT recommended for dysfunctional uterine bleeding per FDA labeling due to prolonged action and difficulty predicting withdrawal bleeding 6

Management of Acute Heavy Bleeding

For acute bleeding episodes requiring rapid control:

• High-dose combined oral contraceptives for 10-20 days achieves rapid bleeding control 3
• High-dose estrogen is most effective for acute episodes 5
• NSAIDs can be added for 5-7 days to reduce bleeding volume by 30-50% 3
• For hemodynamically unstable women with uncontrolled bleeding, high-dose oral or injectable progestin-only medications may be considered short-term 4

When Medical Treatment Fails

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

• Transvaginal ultrasonography (saline infusion sonohysterography has 96-100% sensitivity for uterine/endometrial pathology) 1
• Hysteroscopy to visualize the endometrial cavity and diagnose focal lesions possibly missed by endometrial sampling 1, 2
• Endometrial biopsy (preferred over dilation and curettage due to lower invasiveness, safety, and cost) 1

Surgical Options After Medical Failure

When medical management fails, is contraindicated, or not tolerated: 1

• Endometrial ablation (second-generation techniques like thermal balloon, microwave, radiofrequency) has efficacy comparable to LNG-IUD 1, 2
• Hysterectomy is definitive treatment for patients who have completed childbearing and desire permanent resolution 2, 3

Critical Special Population Considerations

In women with cardiovascular disease or post-SCAD: NSAIDs and tranexamic acid should be avoided due to MI and thrombosis risk, making the LNG-IUD the preferred option. 1, 2, 3 Hormonal therapy is relatively contraindicated in this population, requiring careful clinical judgment. 1, 2

Common Pitfalls to Avoid

• Do not use injectable DMPA as first-line treatment for dysfunctional uterine bleeding—it is contraindicated per FDA labeling 6
• Do not rely on endometrial biopsy alone to rule out focal lesions, as sensitivity varies significantly 1, 2
• Do not prescribe estrogen therapy for anovulatory bleeding except in profuse bleeding unresponsive to progestin, as it increases risk of endometrial hyperplasia and cancer 7
• Always rule out pregnancy, coagulopathy (especially von Willebrand disease in adolescents), and structural pathology before diagnosing dysfunctional uterine bleeding 1, 5