What are the oral outpatient medication options for a female patient of reproductive age presenting with acute abnormal uterine bleeding?

Oral Outpatient Medications for Acute Abnormal Uterine Bleeding

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

Immediate Assessment Requirements

Before initiating treatment, you must:

• Perform a pregnancy test (β-hCG) in all reproductive-age women to exclude pregnancy as the cause 2, 1
• Assess hemodynamic stability - urgent evaluation is warranted if bleeding saturates a large pad or tampon hourly for ≥4 hours 2
• Order complete blood count with platelets, thyroid-stimulating hormone, and prolactin levels 2, 1
• Obtain combined transabdominal and transvaginal ultrasound with Doppler as first-line imaging to identify structural causes 2

First-Line Medical Treatment Options

Most Effective: Levonorgestrel-Releasing IUD (LNG-IUD)

• Reduces menstrual blood loss by 71-95% with efficacy equivalent to endometrial ablation 1, 3
• Preferred option for patients with cardiovascular disease due to minimal systemic absorption and avoidance of MI/thrombosis risk associated with NSAIDs and tranexamic acid 1, 3
• Preferred for patients on anticoagulation therapy due to minimal systemic absorption 1, 3

Alternative Oral Medications

Combined Hormonal Contraceptives (CHCs):

• Effective for ovulatory dysfunction bleeding and can reduce menstrual flow by approximately 50% 1, 4
• Can be combined with NSAIDs to further reduce bleeding volume 1
• For acute bleeding episodes, use high-dose estrogen-progestin oral contraceptives in a multidose regimen 5

Oral Progestins:

• Administer for 21 days per month for menstrual blood loss reduction in women with cyclic heavy bleeding 1
• Medroxyprogesterone acetate 10 days per month is effective for anovulatory bleeding 6
• Reduces blood loss by only 20% in ovulatory women, making it less effective than LNG-IUD 3

Tranexamic Acid:

• Decreases menstrual flow by approximately 50% and is a viable option for heavy menstrual bleeding 1, 4
• Can be used intravenously for severe acute bleeding in hemodynamically stable patients 5
• AVOID in patients with cardiovascular disease or post-SCAD due to MI and thrombosis risk 2, 1

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):

• Decrease bleeding by 30-50% 4
• Can be combined with hormonal methods and tranexamic acid 1, 5
• AVOID in patients with cardiovascular disease due to MI risk 2, 1

Critical Contraindications and Special Populations

Patients with Cardiovascular Disease:

• LNG-IUD is the preferred option due to minimal systemic absorption 1, 3
• Avoid NSAIDs and tranexamic acid due to association with MI and thrombosis 2, 1
• Hormonal therapy is relatively contraindicated despite being first-line for most AUB cases 1

Patients on Antiplatelet Therapy:

• Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate 2, 1
• Progestin-eluting IUDs are preferred due to minimal systemic absorption 1

Treatment Escalation Algorithm

If bleeding persists after 2-3 treatment cycles:

• Perform hysteroscopy to exclude focal lesions missed by endometrial sampling 1, 3
• Consider endometrial ablation as a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Hysterectomy is definitive treatment when medical management fails or is contraindicated 1

Common Pitfalls to Avoid

• Do not use endometrial biopsy alone to rule out focal lesions - it has variable sensitivity; saline infusion sonohysterography has high sensitivity (96-100%) and negative predictive value (94-100%) 2, 1
• Do not recommend ascorbic acid - it is not supported by evidence-based guidelines 1
• Avoid estrogen therapy in anovulatory bleeding except for profuse bleeding unresponsive to progestin, as it increases endometrial hyperplasia and cancer risk 3

Referral Indications

Refer to gynecology if:

• Failed medical management after appropriate trial 2
• Endometrial sampling shows hyperplasia or malignancy 2
• Postmenopausal bleeding with endometrial thickness ≥4 mm 2