Treatment Options for 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, 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—urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
- Obtain combined transabdominal and transvaginal ultrasound with Doppler as first-line imaging to identify structural causes (polyps, adenomyosis, fibroids, malignancy) 2
Additional baseline testing should include thyroid-stimulating hormone, prolactin levels, and complete blood count with platelets 1, 2
Medical Management Algorithm
First-Line Treatment
The LNG-IUD stands as the gold standard medical therapy, demonstrating 71-95% reduction in menstrual blood loss with efficacy equivalent to endometrial ablation 1. This device provides localized progestin delivery with minimal systemic absorption, making it particularly advantageous for women who cannot tolerate systemic hormones 1.
Alternative First-Line Options
When LNG-IUD is not suitable or declined:
- Combined hormonal contraceptives (CHCs) are highly effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume 1
- Oral progestins administered for 21 days per month effectively reduce menstrual blood loss in women with cyclic heavy bleeding 1
- Tranexamic acid is a viable high-efficacy option for heavy menstrual bleeding 1, 3
- NSAIDs may be utilized alongside hormonal methods and tranexamic acid to decrease menstrual bleeding 3
Critical Caveat for Cardiovascular Disease
In women with cardiovascular disease or post-SCAD, NSAIDs and tranexamic acid must be avoided due to MI and thrombosis risk—the LNG-IUD becomes the mandatory preferred option in this population. 1, 2 For patients on antiplatelet therapy, reassess the indication and discontinue if appropriate before initiating treatment, with progestin-eluting IUDs preferred 1, 2.
Surgical Management
When to Consider Surgery
If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is indicated 1. Hysteroscopy allows direct visualization of the endometrial cavity and endocervix, diagnosing focal lesions potentially missed by endometrial sampling 1.
Surgical Options
Endometrial ablation serves as a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1, 2
- Important warning: Endometrial ablation carries long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis—thorough informed consent is essential 1
Hysterectomy is the most definitive treatment when medical management fails or is contraindicated, particularly appropriate for women who have completed childbearing and desire permanent resolution 1, 2
Diagnostic Pitfalls to Avoid
Endometrial biopsy alone should never be used to rule out focal lesions due to variable sensitivity 1. Saline infusion sonohysterography demonstrates high sensitivity (96-100%) and negative predictive value (94-100%) for assessing intracavitary pathology and can distinguish between leiomyomas and endometrial polyps with 97% accuracy 2.
Referral Indications
Refer to gynecology when: