Treatment of Abnormal Uterine Bleeding
The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for AUB, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1
Initial Diagnostic Requirements Before Treatment
Before initiating any treatment, perform mandatory pregnancy testing in all reproductive-age women to rule out pregnancy-related bleeding. 1, 2 Order a complete blood count with platelets to assess for anemia and thrombocytopenia, and measure thyroid-stimulating hormone and prolactin levels to exclude thyroid dysfunction and hyperprolactinemia. 2 Obtain a detailed menstrual history documenting regularity, duration, frequency, and volume of bleeding, and assess for signs of hyperandrogenism (acne, hirsutism) suggesting polycystic ovary syndrome. 2
Use transvaginal ultrasonography if structural etiology is suspected or symptoms persist despite treatment. 1 Combined transabdominal and transvaginal ultrasound with Doppler serves as first-line imaging to detect endometrial hyperplasia, polyps, adenomyosis, and leiomyomas. 2
Medical Management Algorithm
First-Line Treatment Options
LNG-IUD is the preferred first-line option for most patients, demonstrating 71-95% reduction in menstrual blood loss with efficacy equivalent to endometrial ablation. 1, 2
Combined hormonal contraceptives (CHCs) are effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume. 1, 2 In adolescents with mild to moderate bleeding, CHCs serve as first-line treatment. 3, 2
Oral progestins administered for 21 days per month reduce menstrual blood loss and are effective for women with cyclic heavy bleeding related to the menstrual cycle. 1, 2 Note that injectable medroxyprogesterone acetate is NOT recommended for dysfunctional uterine bleeding due to its prolonged action and difficulty predicting withdrawal bleeding timing. 4
Tranexamic acid is a viable option with high efficacy for heavy menstrual bleeding. 1, 2, 5
NSAIDs may be utilized with hormonal methods to decrease menstrual bleeding. 1, 2
Critical Special Population Considerations
In patients with cardiovascular disease or post-SCAD, the LNG-IUD becomes the mandatory preferred option because NSAIDs and tranexamic acid carry unacceptable MI and thrombosis risks. 1, 2 For patients on antiplatelet therapy, reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating AUB treatment, with progestin-eluting IUDs preferred due to minimal systemic absorption. 1
In adolescents, progestin-only options (oral, injectable, or intrauterine) serve as alternatives when CHCs are contraindicated. 3, 2
Surgical Management
When to Escalate to Surgery
If bleeding persists despite initial medical therapy, perform hysteroscopy to visualize the endometrial cavity and diagnose focal lesions potentially missed by endometrial sampling. 1, 2 Endometrial biopsy alone should not be used to rule out focal lesions due to variable sensitivity; saline infusion sonohysterography has high sensitivity and negative predictive value for assessing intracavitary pathology. 1
Surgical Options
Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD. 1, 2 However, provide thorough informed consent regarding long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis. 1
Hysteroscopic removal of polyps may be considered for bleeding with structural abnormalities, though rarely needed in adolescents. 3
Hysterectomy is the definitive treatment when medical management fails or is contraindicated, particularly in postmenopausal women with symptomatic fibroids and for patients who have completed childbearing and desire permanent resolution. 1, 2
Common Pitfalls to Avoid
Do not use ascorbic acid for AUB treatment—it is not recommended by evidence-based guidelines. 1
In postmenopausal women, endometrial thickness ≥5 mm on transvaginal ultrasound mandates endometrial tissue sampling, while thickness <4 mm has nearly 100% negative predictive value for cancer. 2
When using combined oral contraceptives for breakthrough bleeding, rule out pregnancy and pathology before changing to a preparation with higher estrogen content, as this may increase thromboembolic disease risk. 6
In women 35 years or older with recurrent anovulation, women younger than 35 years with risk factors for endometrial cancer, and women with excessive bleeding unresponsive to medical therapy, perform endometrial biopsy to exclude hyperplasia or malignancy. 7