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 on anticoagulation:

• 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
• For patients on antiplatelet therapy, reassess the indication and discontinue if appropriate before initiating treatment 1, 2

Women with inherited bleeding disorders:

• All hormonal methods and tranexamic acid can be used effectively 4

When Initial Treatment Fails

If bleeding persists despite initial medical therapy:

• Further investigation with hysteroscopy is indicated to diagnose focal lesions potentially missed by endometrial sampling 1, 2
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine and endometrial pathology 2
• Important pitfall: Endometrial biopsy alone should not be used to rule out focal lesions due to variable sensitivity 1

Surgical options after failed medical management:

• Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Hysterectomy is the definitive treatment when medical management fails or is contraindicated, providing complete resolution of symptoms 1, 2

Critical Pitfalls to Avoid

• Never rely on endometrial biopsy alone to exclude focal lesions – it has variable sensitivity and can miss polyps or submucous fibroids 1
• Do not prescribe NSAIDs or tranexamic acid to women with cardiovascular disease history 1, 2
• Avoid ascorbic acid – it is not recommended by ACOG or ACR for abnormal uterine bleeding 1
• Ensure informed consent for endometrial ablation regarding long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis 1

Referral Indications

Refer to gynecology when:

• Medical management fails 2
• Endometrial sampling shows hyperplasia or malignancy 2
• Postmenopausal bleeding with endometrial thickness ≥4 mm 2