What is the appropriate management for a woman of reproductive age with no known medical history presenting with abnormal uterine bleeding?

Management of Abnormal Uterine Bleeding in Reproductive-Age Women

Immediate Assessment

All reproductive-age women presenting with abnormal uterine bleeding must first undergo pregnancy testing (β-hCG) to rule out pregnancy-related causes, as this is the most critical initial step. 1, 2

Assess for Hemodynamic Instability

• Urgent evaluation is required if bleeding saturates a large pad or tampon hourly for at least 4 hours 1
• Perform abdominal examination to assess for hemodynamic instability and palpate for enlarged uterus or masses 1
• Perform speculum examination to visualize cervix and vagina, excluding cervical or vaginal sources 1
• Complete bimanual examination to assess uterine size, contour, mobility, and adnexal masses 1

Diagnostic Workup

Initial Laboratory Testing

• Pregnancy test (β-hCG) - mandatory first step 1, 2
• Thyroid-stimulating hormone (TSH) and prolactin levels - to evaluate for endocrine causes 1
• Complete blood count with platelets - to assess for anemia and coagulopathy 2

First-Line Imaging

Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study for identifying structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1, 3

• 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 1
• MRI pelvis should be considered when ultrasound incompletely visualizes the uterus or findings are indeterminate 1

Classification Using PALM-COEIN System

The PALM-COEIN classification categorizes causes as follows 1, 2:

Structural causes (PALM):

• Polyp - common in women over 40 1
• Adenomyosis - frequent in premenopausal women in their 40s 1, 2
• Leiomyoma (fibroids) - most common structural cause in women under 40 1
• Malignancy and hyperplasia - requires endometrial biopsy 1

Non-structural causes (COEIN):

• Coagulopathy - screen adolescents and those with treatment failure 1
• Ovulatory dysfunction - causes irregular, heavy bleeding 1
• Endometrial disorders - molecular deficiencies in hemostasis regulation 1
• Iatrogenic - anticoagulants (70% experience heavy bleeding), IUDs, hormonal medications 1
• Not yet classified 1

Medical Management Algorithm

First-Line Treatment

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 2

Alternative Medical Options (in order of preference):

1. Combined hormonal contraceptives (CHCs) - effective for ovulatory dysfunction bleeding, can be combined with NSAIDs to further reduce bleeding volume 2

2. Oral progestins - administer for 21 days per month for menstrual blood loss reduction in women with cyclic heavy bleeding 2, 4

   • Dosing: 400 mg progesterone at bedtime for 10 days for secondary amenorrhea 4
   • For prevention of endometrial hyperplasia: 200 mg daily at bedtime for 12 continuous days per 28-day cycle 4

3. Tranexamic acid - viable option with high efficacy for heavy menstrual bleeding 2

4. NSAIDs - can reduce bleeding volume when combined with hormonal therapy 2

Critical Contraindications and Special Populations

Patients with Cardiovascular Disease

In women with cardiovascular disease or post-SCAD, NSAIDs and tranexamic acid must be avoided due to MI and thrombosis risk; the levonorgestrel-releasing IUD becomes the preferred option. 1, 2

Patients on Antiplatelet Therapy

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

Patients on Anticoagulation

• Approximately 70% of women on anticoagulation experience heavy menstrual bleeding 1
• Oral anticoagulants (particularly rivaroxaban) cause abnormal uterine bleeding in 9-14% of reproductive-age women, with 27% experiencing prolonged bleeding >8 days 1

When to Refer to Gynecology

Immediate gynecology referral is required for: 1

• Failed medical management
• Endometrial sampling showing hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm

Surgical Management

Indications for Surgical Intervention

If bleeding persists despite initial medical therapy, further investigation with hysteroscopy is indicated to diagnose focal lesions potentially missed by endometrial sampling 2

Surgical options in order of invasiveness:

1. Endometrial ablation - less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 2

   • Important caveat: Long-term complications include postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis; thorough informed consent required 2

2. Hysterectomy - most definitive treatment when medical management fails or is contraindicated, providing complete resolution of symptoms and significantly better health-related quality of life 1, 2

Common Pitfalls to Avoid

• Never use endometrial biopsy alone to rule out focal lesions - it has variable sensitivity; saline infusion sonohysterography has superior sensitivity and negative predictive value 2
• Do not prescribe progesterone capsules to pregnant women - cases of cleft palate, cleft lip, hypospadias, ventricular septal defect, and patent ductus arteriosus have been reported 4
• Warn patients taking progesterone capsules about drowsiness/dizziness - some women experience extreme dizziness, blurred vision, difficulty speaking, difficulty walking, and feeling abnormal; take at bedtime in standing position with water 4
• Avoid NSAIDs and tranexamic acid in cardiovascular disease patients - associated with MI and thrombosis 1, 2