What is the management approach for abnormal menstruation in a patient?

Management of Abnormal Menstruation

Begin with combined transabdominal and transvaginal ultrasound with Doppler as your first-line imaging study after confirming hemodynamic stability and ruling out pregnancy. 1

Immediate Assessment

Hemodynamic Evaluation

• Urgent evaluation is required if bleeding saturates a large pad or tampon hourly for at least 4 hours. 2, 1
• Assess vital signs for hemodynamic instability including tachycardia, hypotension, or orthostatic changes. 1
• Perform abdominal examination to palpate for enlarged uterus or masses. 1

Mandatory Initial Testing

• Pregnancy test (β-hCG) is mandatory in all reproductive-age women with abnormal uterine bleeding. 2, 1, 3
• Measure thyroid-stimulating hormone (TSH) and prolactin levels to evaluate for ovulatory dysfunction. 2, 1, 3
• Complete blood count to assess for anemia. 3

Physical Examination

• Perform speculum examination to visualize cervix and vagina, excluding cervical or vaginal bleeding sources. 1
• Conduct bimanual examination to assess uterine size, contour, mobility, and adnexal masses. 1

Diagnostic Imaging

First-Line Imaging

• Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study. 1
• This identifies structural causes: polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy. 1, 3
• In postmenopausal women, endometrial thickness <4 mm has nearly 100% negative predictive value for cancer. 1

Second-Line Imaging

• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine pathology. 2, 1
• This distinguishes between leiomyomas and endometrial polyps with 97% accuracy. 1
• MRI pelvis is indicated when ultrasound incompletely visualizes the uterus or findings are indeterminate. 1

Classification Using PALM-COEIN

The PALM-COEIN system categorizes causes as: 2, 1

• Structural (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
• Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified

Medical Management

First-Line Treatment for Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS 20 μg/day) is the most effective medical treatment, reducing menstrual blood loss by 71-95%. 2, 3, 4, 5, 6

• Efficacy is comparable to endometrial ablation. 2, 3
• Works primarily at the endometrial level with minimal systemic progesterone absorption. 2
• Provides contraception simultaneously. 2

Acute Bleeding Management

• Tranexamic acid is the most effective treatment for acute bleeding, reducing menstrual bleeding by 40-60%. 3, 4, 5
• Contraindicated in patients with history of thromboembolism or active cardiovascular disease. 3
• NSAIDs (except aspirin) reduce blood loss by 20-60% when used for 5-7 days during bleeding episodes. 2, 3, 4, 5, 6
• Avoid aspirin as it paradoxically increases bleeding. 3

Hormonal Options

• Combined oral contraceptives reduce menstrual blood loss and can be used for 10-20 days in acute settings. 2, 4, 5, 6
• Oral progestins (cyclic, 21 days per month) are effective for ovulatory dysfunction. 2, 4, 5
• For postmenopausal women on estrogen therapy, progesterone 200 mg daily at bedtime for 12 continuous days per 28-day cycle prevents endometrial hyperplasia. 7
• For secondary amenorrhea, progesterone 400 mg at bedtime for 10 days. 7

Treatment for Bleeding on Contraceptive Implants

If irregular bleeding occurs with implant use: 2

• Rule out underlying gynecologic problems (STDs, pregnancy, polyps, fibroids). 2
• NSAIDs for 5-7 days during bleeding episodes. 2
• Low-dose combined oral contraceptives or estrogen for 10-20 days if medically eligible. 2
• Reassure patients that amenorrhea requires no treatment. 2

Special Populations

Patients on Antiplatelet/Anticoagulation Therapy

• Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate. 2, 1, 3
• Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to MI and thrombosis risk. 2, 1
• Progestin-eluting intrauterine devices (levonorgestrel 20 μg/day) are particularly useful, reducing bleeding by 71-95%. 2
• Systemic progesterone levels increase minimally with IUDs; main effect is endometrial. 2

Patients with Prior SCAD (Spontaneous Coronary Artery Dissection)

• Hormonal therapy is relatively contraindicated. 2
• If HT must be used, use transdermal systemic agents to minimize thrombotic factor activation. 2
• Locally applied vaginal estrogen is generally safe due to minimal systemic absorption. 2

Patients with Bleeding Disorders

• Refer to hematology if personal/family history of bleeding (epistaxis, dental bleeding, easy bruising) or refractory bleeding. 3
• All hormonal methods and tranexamic acid can be used. 4

Surgical Referral Criteria

Refer to gynecology if: 1, 3

• Medical treatment fails after 3 months
• Endometrial biopsy shows hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm
• Persistent hemodynamic instability
• Patient desires definitive treatment

Surgical Options

• Second-generation endometrial ablation (thermal balloon, microwave, radiofrequency) or first-generation techniques (endometrectomy, roller-ball). 5
• Hysterectomy provides complete symptom resolution and significantly better quality of life compared to other therapies. 1
• Hysterectomy should be performed via vaginal or laparoscopic routes when indicated. 5

Critical Pitfalls to Avoid

• Never skip pregnancy testing in reproductive-age women. 2, 1, 3
• Do not use tranexamic acid in patients with thromboembolic history or active cardiovascular disease. 3
• Avoid NSAIDs and tranexamic acid in patients with known cardiovascular disease. 2, 1
• Do not prescribe progesterone capsules to patients with peanut allergies (contains peanut oil). 7
• Transvaginal ultrasound is not recommended in virgins; use transabdominal imaging. 2
• Cyclic progestogens do not significantly reduce bleeding in women who ovulate normally. 6
• Endometrial biopsy is preferred over dilation and curettage for diagnosing endometrial hyperplasia or cancer (less invasive, safer, lower cost). 2