What is the best course of treatment for a female of reproductive age with no significant medical history presenting with acute abnormal uterine bleeding (AUB)?

Management of Acute Abnormal Uterine Bleeding in Reproductive-Age Women

For acute AUB in a reproductive-age woman with no significant medical history, first assess hemodynamic stability, then initiate high-dose combined oral contraceptives (3 times daily for 7 days) or intravenous conjugated estrogens (25 mg IV, repeat in 6-12 hours if needed) for rapid bleeding control, followed by transition to levonorgestrel-releasing IUD as definitive first-line therapy. 1, 2, 3

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• 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
• Obtain complete blood count with platelets to assess for anemia and thrombocytopenia. 4

Essential Diagnostic Testing

• Pregnancy test (β-hCG) is mandatory in all reproductive-age women before any treatment. 1, 4
• Order thyroid-stimulating hormone and prolactin levels as part of initial workup. 1, 4
• Perform speculum examination to visualize cervix and vagina, excluding cervical or vaginal bleeding sources. 1

Acute Bleeding Control

For Hemodynamically Stable Patients

Combined oral contraceptives are the preferred first-line acute treatment, administered as monophasic pills containing 35 mcg ethinyl estradiol taken three times daily for 7 days. 3 This regimen typically stops bleeding within 24-48 hours. 3

For Severe Acute Bleeding or Hypovolemia

Intravenous conjugated estrogens 25 mg IV (preferred over IM for faster response) should be administered, with repeat dosing in 6-12 hours if bleeding persists. 2, 3 This provides rapid temporary increase in estrogen levels for immediate hemostasis. 2

Alternative Acute Regimens

• Multidose progestin-only regimen (norethisterone 5 mg three times daily) can be used if estrogen is contraindicated. 3
• Tranexamic acid 1300 mg three times daily is a viable non-hormonal option for acute bleeding. 3, 4

Transition to Long-Term Management

First-Line Definitive Therapy

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 4 This should be placed once acute bleeding is controlled. 4

Alternative Long-Term Options

• Combined hormonal contraceptives can be continued cyclically after acute phase, particularly effective for ovulatory dysfunction. 4
• Oral progestins administered 21 days per month reduce menstrual blood loss in women with cyclic heavy bleeding. 4
• Tranexamic acid reduces menstrual blood loss by 20-60% as a non-hormonal alternative. 5, 4

Diagnostic Imaging After Stabilization

Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study to identify structural causes (polyps, adenomyosis, leiomyomas, endometrial hyperplasia/malignancy). 1 This should be performed once bleeding is controlled to guide definitive management. 1

When to Escalate Imaging

• Saline infusion sonohysterography has 96-100% sensitivity for uterine and endometrial pathology when ultrasound findings are indeterminate. 1
• MRI pelvis should be considered when ultrasound incompletely visualizes the uterus. 1

Critical Caveats and Pitfalls

Contraindications to Estrogen Therapy

Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease due to MI and thrombosis risk; use LNG-IUD as preferred option instead. 1, 4 This is particularly important for post-SCAD patients where hormonal therapy may be relatively contraindicated. 4

Anticoagulation Considerations

Women on oral anticoagulants (particularly rivaroxaban) experience abnormal uterine bleeding in 27% of cases with prolonged bleeding >8 days. 6, 1 Reassess indication for ongoing anticoagulation and consider progestin-eluting IUDs due to minimal systemic absorption. 4

When Medical Management Fails

• Refer to gynecology if medical management fails, endometrial sampling shows hyperplasia/malignancy, or structural abnormalities require surgical intervention. 1
• Hysteroscopy allows visualization of endometrial cavity to diagnose focal lesions potentially missed by endometrial sampling. 4
• Endometrial ablation or hysterectomy should be considered only after failed medical management, with hysterectomy providing definitive resolution. 1, 4

Estrogen Therapy Warnings

Unopposed estrogen increases endometrial cancer risk; adequate diagnostic measures including endometrial sampling must be undertaken in women with persistent or recurring abnormal bleeding. 2 Estrogens should be prescribed at lowest effective doses for shortest duration. 2