What are the treatment options for abnormal uterine bleeding?

Treatment Options for Abnormal Uterine Bleeding

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

Initial Assessment Before Treatment

Before initiating any treatment, perform pregnancy testing in all reproductive-age women to rule out pregnancy as the cause 1, 2. Assess hemodynamic stability urgently if bleeding saturates a large pad or tampon hourly for at least 4 hours 2. Order combined transabdominal and transvaginal ultrasound with Doppler as the first-line imaging study to identify structural causes such as polyps, adenomyosis, leiomyomas, and malignancy 2. Measure thyroid-stimulating hormone, prolactin levels, and complete blood count with platelets before treatment 1, 3.

Medical Management Algorithm

First-Line Treatment Options

• LNG-IUD is the preferred initial therapy, demonstrating 71-95% reduction in menstrual blood loss with efficacy equivalent to endometrial ablation 1
• Combined hormonal contraceptives (CHCs) are effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume 1
• Oral progestins administered for 21 days per month effectively reduce menstrual blood loss in women with cyclic heavy bleeding 1
• Tranexamic acid is a viable non-hormonal option with high efficacy for heavy menstrual bleeding 1, 4
• NSAIDs reduce bleeding by 20-50% and are most effective for ovulatory menorrhagia 5, 4

Treatment Selection Based on Clinical Scenario

For anovulatory bleeding, use combined oral contraceptives as first-line for most patients, providing cycle regulation and reducing bleeding 3. Cyclic progestins are appropriate alternatives when estrogen is contraindicated 3. For ovulatory bleeding (menorrhagia), the LNG-IUD remains most effective, but oral progesterone for 21 days per month and NSAIDs are also effective 5.

Special Population Considerations

Cardiovascular Disease or Post-SCAD Patients

Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease or post-SCAD due to the risk of MI and thrombosis; the levonorgestrel-releasing IUD becomes the preferred option in this population. 1 Hormonal therapy is relatively contraindicated despite being first-line for most AUB cases, requiring careful clinical judgment and consideration of progestin-only IUDs 1.

Patients on Antiplatelet or Anticoagulation Therapy

Reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating AUB treatment 1, 2. Progestin-eluting IUDs are preferred due to minimal systemic absorption 1. Women on anticoagulation should consider progestin-only methods as well as gonadotropin-releasing hormone agonists 4.

Age-Specific Considerations

Endometrial biopsy is mandatory in patients with risk factors for endometrial cancer, including age >45 years, postmenopausal status, obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, and Lynch syndrome 3. Perimenopausal women have a higher risk for endometrial hyperplasia/cancer and should have a lower threshold for endometrial sampling 3. Postmenopausal women with any bleeding require evaluation for endometrial cancer 3.

Surgical Management

When to Consider Surgery

If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is indicated 1. Hysteroscopy allows visualization of the endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 1.

Surgical Options

• Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD for women who have completed childbearing 1, 3
• Hysterectomy is the most appropriate treatment when medical management fails or is contraindicated, providing definitive resolution of all symptoms and significantly better health-related quality of life compared to other therapies 1, 3
• The least invasive surgical route should be chosen based on uterine size and surgical expertise 3

Referral Indications

Refer to a gynecologist for failed medical management, endometrial sampling showing hyperplasia or malignancy, or postmenopausal bleeding with endometrial thickness ≥4 mm 2, 3. Women with hyperplasia with atypia or adenocarcinoma should be referred to a gynecologist or gynecologic oncologist, respectively 5.

Common Pitfalls to Avoid

• Do not use endometrial biopsy alone to rule out focal lesions, as it has variable sensitivity; saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine and endometrial pathology 1, 2
• Endometrial ablation has long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis; provide thorough informed consent 1
• Do not use ascorbic acid for abnormal uterine bleeding, as it is not recommended by established guidelines 1
• If breakthrough bleeding occurs with oral contraceptives, rule out pregnancy and malignancy before attributing it to the medication 6, 7