What are the management options for a patient presenting with uterine bleeding?

Management of Uterine Bleeding

Immediate Assessment and Stabilization

Test for pregnancy immediately in all reproductive-age women presenting with uterine bleeding 1, 2. This is the critical first step that cannot be skipped, as it fundamentally changes management.

Urgent evaluation is required if bleeding saturates a large pad or tampon hourly for at least 4 hours, or if hemodynamic instability is present 1, 2. These patients need:

• Hemodynamic stabilization with volumetric replacement if hypovolemic 3
• High-dose estrogen for acute bleeding episodes 4
• Consideration of massive transfusion protocol if blood loss exceeds 1500 mL 1
• Curettage for patients with acute bleeding resulting in hypovolemia 4

Diagnostic Workup

Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study 2. This identifies structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 2.

Essential laboratory testing includes 2:

• Pregnancy test (β-hCG)
• Complete blood count with hemoglobin/hematocrit
• Thyroid-stimulating hormone
• Prolactin levels
• Coagulation studies (PT/INR, aPTT) if bleeding disorder suspected

Endometrial biopsy or curettage is indicated for 4, 2:

• Women ≥35 years with recurrent anovulation
• Women <35 years with risk factors for endometrial cancer (obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, Lynch syndrome)
• Postmenopausal bleeding with endometrial thickness ≥4 mm
• Persistent bleeding unresponsive to medical therapy

Medical Management: First-Line Therapy

The levonorgestrel-releasing intrauterine system (20 μg/day) is the single most effective medical treatment for heavy menstrual bleeding, achieving 71-95% reduction in menstrual blood loss 1. This should be the default first-line therapy for premenopausal women not desiring immediate pregnancy 1.

Alternative Medical Options by Clinical Scenario:

For anovulatory bleeding 4, 5:

• Adolescents: Medroxyprogesterone acetate 10 mg daily for 10 days each month for ≥3 months 4
• Reproductive age requiring contraception: Combined oral contraceptives 4
• Reproductive age desiring pregnancy: Clomiphene citrate 4
• Perimenopausal patients: Cyclic progestin for 10 days monthly, or low-dose combination oral contraceptives if nonsmoker without vascular disease 4

For ovulatory bleeding (menorrhagia) 5, 6:

• Tranexamic acid: Most effective non-hormonal medical therapy, 1 g orally three times daily during menstruation 6. FDA-approved for ovulatory bleeding 5.
• NSAIDs: Effective for reducing menstrual blood loss 5, 6
• Oral progestins: 21 days per month 5

Critical Contraindications and Pitfalls:

Avoid NSAIDs and tranexamic acid in women on anticoagulation therapy or with cardiovascular disease due to MI and thrombosis risk 1, 2. This is a common and dangerous error.

Tranexamic acid carries thromboembolic risk and is contraindicated in patients with active intravascular clotting 7. Avoid concomitant use with pro-thrombotic medications including Factor IX concentrates and hormonal contraceptives 7.

For patients on anticoagulation (70% experience heavy menstrual bleeding): Reassess indication for ongoing antiplatelet therapy and consider discontinuation if appropriate 2. The levonorgestrel IUD is strongly preferred over systemic hormones 1.

Postpartum Hemorrhage: Specific Protocol

Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of birth 1. Delay reduces benefit by 10% for every 15 minutes—this is time-critical 1.

Give oxytocin 5-10 IU slow IV or IM immediately 1, along with:

• Uterine massage and bimanual compression 1
• Second dose of tranexamic acid 1 g if bleeding continues after 30 minutes or restarts within 24 hours 1
• Intrauterine balloon tamponade if pharmacological management fails 1

Methylergonovine is contraindicated in hypertensive patients 1—a critical safety consideration.

Surgical Management: When Medical Therapy Fails

Hysteroscopic myomectomy is the surgical option for pedunculated submucosal fibroids causing heavy bleeding 8, 2.

For general heavy menstrual bleeding refractory to medical management 8:

• Endometrial ablation (second-generation techniques: thermal balloon, microwave, radiofrequency) for women not desiring future fertility 8, 1
• Laparoscopic or open myomectomy for fibroids in women desiring pregnancy 8
• Uterine artery embolization for fibroids 8, 1

Hysterectomy is the definitive treatment 5, 6, providing complete resolution and significantly better health-related quality of life compared to other therapies 2. This is appropriate for postmenopausal patients with negative endometrial biopsy or when all other treatments have failed 8.

Referral Indications

Refer to gynecology for 2:

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

Refer to gynecologic oncology for hyperplasia with atypia or adenocarcinoma 4.

Special Population: Inherited Bleeding Disorders

Consider von Willebrand disease in all patients with menorrhagia—it affects 10-20% of women with objectively documented menorrhagia 9. Perform vWD workup (factor VIII, vWF antigen, vWF functional assay) in women with personal or family history of bleeding 9.

Desmopressin (DDAVP) is effective for menorrhagia in von Willebrand disease 4, 9, avoiding risks of blood product transmission 4.