What are the recommended medications for dysfunctional uterine bleeding?

Recommended Medications for Dysfunctional Uterine Bleeding

First-Line Medical Treatment

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

Why LNG-IUD is Superior

• The LNG-IUD demonstrates the highest reduction in menstrual blood loss (71-95%) compared to all other medical therapies 1, 2
• It has minimal systemic absorption, making it the preferred option for women with cardiovascular disease, post-SCAD, or those on anticoagulation therapy 1, 2
• Its efficacy is equivalent to endometrial ablation, a surgical intervention 1

Alternative Hormonal Therapies

Combined Hormonal Contraceptives (CHCs)

• Effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume 1
• Appropriate for reproductive-age women who also require contraception 3
• Low-dose combination oral contraceptives may be used in perimenopausal non-smokers without vascular disease 3

Oral Progestins

• Administer for 21 days per month for menstrual blood loss reduction in women with cyclic heavy bleeding 1
• Medroxyprogesterone acetate 2.5-10 mg daily for 5-10 days produces secretory transformation of adequately primed endometrium 4
• However, oral progestogens reduce blood loss by only 20% in ovulatory women, significantly less effective than LNG-IUD 2, 5
• Critical caveat: Progestins are highly effective for anovulatory bleeding but have limited efficacy in ovulatory dysfunctional uterine bleeding 3, 5

Norethindrone Acetate

• FDA-approved dosing: 2.5-10 mg daily for 5-10 days for abnormal uterine bleeding due to hormonal imbalance 4
• Progestin withdrawal bleeding typically occurs within 3-7 days after discontinuation 4
• Patients with recurrent episodes may benefit from planned menstrual cycling 4

Non-Hormonal Medical Therapies

Tranexamic Acid

• Highly effective antifibrinolytic agent reducing menstrual blood loss by approximately 50% 1, 6
• Represents the most effective non-hormonal medical therapy available 6
• Critical contraindication: Avoid in women with cardiovascular disease or post-SCAD due to MI and thrombosis risk 1, 7
• Useful for women in whom estrogens are contraindicated 5

NSAIDs (Prostaglandin Synthetase Inhibitors)

• Reduce menstrual blood loss by 25-35%, with greater proportional reduction in women with more excessive bleeding 5
• Can be combined with combined hormonal contraceptives for enhanced efficacy 1
• Must be avoided in patients with cardiovascular disease due to MI risk 1, 7

Treatment Algorithm by Clinical Scenario

For Anovulatory Bleeding

• Oral medroxyprogesterone acetate 10 days each month for ≥3 months in adolescents 3
• Oral contraceptives for reproductive-age women requiring contraception 3
• Cyclic progestin or cyclic conjugated equine estrogens for perimenopausal patients 3
• Estrogen therapy is contraindicated except for profuse anovulatory bleeding unresponsive to progestin, as it increases endometrial hyperplasia and cancer risk 2, 8

For Ovulatory Bleeding (Most Difficult to Manage)

• LNG-IUD as first-line due to superior efficacy 1, 2
• Prolonged progestin use, oral contraceptives, NSAIDs, or antifibrinolytic agents as alternatives 3
• Combination of two or more agents often required for successful control 3

For Acute Bleeding Episodes

• High-dose estrogen for acute bleeding control 3
• Curettage indicated for patients with acute bleeding resulting in hypovolemia 3

Special Populations

• Cardiovascular disease/post-SCAD patients: LNG-IUD is the only appropriate first-line option 1, 2
• Anticoagulation therapy patients: LNG-IUD preferred due to minimal systemic absorption 2
• Patients on antiplatelet therapy: Reassess indication and discontinue if appropriate before initiating treatment; prefer progestin-eluting IUDs 1, 7

When to Escalate Care

• Escalate if bleeding saturates a large pad/tampon hourly for ≥4 hours 7, 2
• Perform hysteroscopy if bleeding persists after 2-3 treatment cycles to exclude focal lesions missed by endometrial sampling 1, 2
• Refer to gynecology for failed medical management, endometrial sampling showing hyperplasia/malignancy, or postmenopausal bleeding with endometrial thickness ≥4 mm 7

Common Pitfalls to Avoid

• Do not use oral progestogens as first-line in ovulatory women—they achieve only 20% reduction in blood loss compared to 71-95% with LNG-IUD 2, 5
• Do not prescribe NSAIDs or tranexamic acid to patients with cardiovascular disease 1, 7
• Do not use estrogen therapy for anovulatory bleeding except in profuse bleeding unresponsive to progestin 2, 8
• Always test for pregnancy in all reproductive-age women before initiating treatment 1, 7