What is the initial treatment approach for a female of reproductive age with abnormal uterine bleeding and no significant medical history?

Initial Treatment of Abnormal Uterine Bleeding in Reproductive-Age Women

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for abnormal uterine bleeding in reproductive-age women with no significant medical history, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1

Essential Initial Steps

Before initiating treatment, three critical assessments must be completed:

• Pregnancy testing is mandatory in all reproductive-age women to rule out pregnancy-related bleeding 1, 2
• Assess hemodynamic stability immediately – urgent evaluation is warranted 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 (polyps, adenomyosis, leiomyomas, endometrial hyperplasia/malignancy) 2

Additional baseline laboratory work should include thyroid-stimulating hormone, prolactin levels, and complete blood count with platelets 1, 2

First-Line Medical Treatment Algorithm

Primary Option: LNG-IUD

• The LNG-IUD demonstrates 71-95% reduction in menstrual blood loss and has efficacy equivalent to endometrial ablation 1
• This is recommended by the American College of Obstetricians and Gynecologists as the most effective first-line medical treatment 1
• Particularly advantageous because it provides long-term management with minimal systemic absorption 1

Alternative First-Line Options

Combined hormonal contraceptives (CHCs):

• Effective for ovulatory dysfunction bleeding 1
• Can be combined with NSAIDs to further reduce bleeding volume 1
• Appropriate for women without cardiovascular contraindications 1

Oral progestins:

• Administer for 21 days per month for menstrual blood loss reduction 1
• Effective for women with cyclic heavy bleeding related to the menstrual cycle 1, 3

Tranexamic acid:

• Viable option for heavy menstrual bleeding with high efficacy 1
• Critical caveat: Avoid in patients with cardiovascular disease or post-SCAD due to MI and thrombosis risk 1, 2

NSAIDs:

• May be utilized with hormonal methods to decrease menstrual bleeding 1
• Must be avoided in women with cardiovascular disease or post-SCAD 1, 2

Special Population Considerations

Women with cardiovascular disease or post-SCAD:

• The LNG-IUD becomes the strongly preferred option due to minimal systemic absorption 1
• NSAIDs and tranexamic acid are contraindicated due to MI and thrombosis risk 1, 2
• Hormonal therapy is relatively contraindicated despite being first-line for most AUB cases 1

Women on antiplatelet 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 therapy:

• Approximately 70% experience heavy menstrual bleeding 2
• Progestin-only methods and GnRH agonists should be considered 4

Management of Treatment Failure

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
• Endometrial biopsy alone should not be used to rule out focal lesions due to variable sensitivity 1
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine and endometrial pathology 2

Surgical Options When Medical Management Fails

Endometrial ablation:

• Less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Important caveat: Long-term complications include postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis – thorough informed consent is required 1

Hysterectomy:

• Most definitive treatment when medical management fails or is contraindicated 1
• Particularly appropriate for postmenopausal women with symptomatic fibroids 1
• Provides complete resolution of symptoms and significantly better health-related quality of life compared to other therapies 2

Common Pitfalls to Avoid

• Never skip pregnancy testing in reproductive-age women, regardless of contraceptive use 1, 2
• Do not prescribe NSAIDs or tranexamic acid to women with cardiovascular disease 1, 2
• Do not rely on endometrial biopsy alone to exclude focal lesions – use saline infusion sonohysterography or hysteroscopy 1, 2
• Do not delay referral to gynecology if endometrial sampling shows hyperplasia or malignancy, or if postmenopausal bleeding occurs with endometrial thickness ≥4 mm 2