What is the best approach to manage abnormal uterine bleeding in a patient with no known comorbidities?

Management of Abnormal Uterine Bleeding in a Patient Without Comorbidities

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 and Diagnostic Workup

Before initiating treatment, complete the following essential evaluations:

• Pregnancy test (β-hCG) must be performed in all reproductive-age women to exclude pregnancy as the cause 2, 1
• Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study to identify structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 2
• Laboratory testing should include thyroid-stimulating hormone, prolactin levels, and complete blood count with platelets 2, 1
• Physical examination should include abdominal palpation for enlarged uterus or masses, speculum examination to visualize cervix/vagina and exclude cervical or vaginal bleeding sources, and bimanual examination to assess uterine size, contour, mobility, and adnexal masses 2

The PALM-COEIN classification system should guide your diagnostic framework, categorizing structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) versus non-structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified) 2, 1.

Medical Management Algorithm

First-Line Treatment Options

For patients without contraindications, proceed with the following hierarchy:

• Levonorgestrel-releasing IUD (LNG-IUD): This is the most effective option, demonstrating 71-95% reduction in menstrual blood loss with efficacy equivalent to endometrial ablation 1. This should be your default first choice.

• Combined hormonal contraceptives (CHCs): Particularly effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume 1

• Oral progestins: Administer for 21 days per month for menstrual blood loss reduction, effective for women with cyclic heavy bleeding related to the menstrual cycle 1

• Tranexamic acid: A viable option with high efficacy for heavy menstrual bleeding 1, 3

• NSAIDs: May be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding 3

Treatment Monitoring and Escalation

If bleeding persists despite initial medical therapy after 3 months:

• Further investigation with hysteroscopy is indicated to visualize the endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 1
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine and endometrial pathology, distinguishing between leiomyomas and endometrial polyps with 97% accuracy 2

Important caveat: Endometrial biopsy alone should not be used to rule out focal lesions due to variable sensitivity 1

Surgical Management

When medical management fails or is contraindicated:

• Endometrial ablation: A less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1. However, be aware of long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis—thorough informed consent is essential 1

• Hysterectomy: The most definitive treatment providing complete resolution of symptoms and significantly better health-related quality of life compared to other therapies 2, 1. This is most appropriate when medical management fails or is contraindicated 1

Referral Indications

Refer to gynecology when:

• Medical management has failed 2
• Endometrial sampling shows hyperplasia or malignancy 2
• Postmenopausal bleeding with endometrial thickness ≥4 mm 2
• Hyperplasia with atypia or adenocarcinoma is identified (refer to gynecologic oncologist) 4

Common Pitfalls to Avoid

• Do not skip pregnancy testing in reproductive-age women—this is a frequent oversight 2, 1
• Do not rely solely on endometrial biopsy to exclude focal lesions; use saline infusion sonohysterography or hysteroscopy for definitive evaluation 1
• Assess hemodynamic stability urgently if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
• Consider age-related risk factors for endometrial cancer, particularly in women over 40 where endometrial polyps become more common 2