What is the best management approach for a patient with repeated abnormal uterine bleeding who has undergone three dilatation and curettage (D&C) procedures?

Management of Repeated Abnormal Uterine Bleeding After 3 Curettages

After three failed curettage procedures for abnormal uterine bleeding, you must stop repeating curettage and transition to definitive management with either the levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line medical therapy or proceed directly to surgical intervention (endometrial ablation or hysterectomy), depending on the underlying pathology and patient's fertility desires. 1

Critical First Step: Rule Out Life-Threatening Pathology

Before proceeding with any treatment plan, you must immediately exclude:

• Gestational trophoblastic neoplasia (GTN): Multiple curettages with persistent bleeding is a red flag. Check serial hCG levels—if plateauing for 4 consecutive values over 3 weeks, rising >10% for 3 values over 2 weeks, or persisting 6+ months, this is GTN until proven otherwise. 2

• Uterine arteriovenous malformation (UAVM): This is specifically associated with repeated bleeding after D&C and can be life-threatening. Order Doppler ultrasonography immediately—look for high-velocity, low-resistance flow patterns. If confirmed, uterine artery embolization must precede any further curettage. 3

• Endometrial cancer/hyperplasia: In postmenopausal women or those with risk factors (obesity, diabetes, unopposed estrogen, Lynch syndrome), the endometrial biopsy from prior curettages must be reviewed. If inadequate sampling or persistent symptoms, hysteroscopy with directed biopsy is mandatory. 2, 4

Why Multiple Curettages Fail and Cause Harm

Multiple curettages should be avoided because they cause endometrial scarring (Asherman syndrome), cervical stenosis, and can delay diagnosis of serious pathology. 2, 5 The American College of Obstetricians and Gynecologists specifically warns that a second curettage may be considered in select cases, but beyond that, you're causing more harm than benefit. 2

Definitive Medical Management Algorithm

First-Line: LNG-IUD (20 μg/day)

The LNG-IUD reduces menstrual blood loss by 71-95% and has efficacy equivalent to endometrial ablation without surgery. 1, 5 This is your best option if:

• Structural pathology (fibroids, polyps, adenomyosis) has been excluded or is minimal
• Patient desires future fertility preservation
• No contraindications exist (active pelvic infection, uterine anomaly, current pregnancy)

The LNG-IUD works through local endometrial suppression with minimal systemic absorption, making it ideal for patients with cardiovascular disease where systemic hormones are contraindicated. 1, 5

Second-Line Medical Options

If LNG-IUD fails or is contraindicated:

• Tranexamic acid: Reduces bleeding by 30-50% through antifibrinolytic action. Avoid in patients with cardiovascular disease or thrombosis risk. 1, 5

• Combined oral contraceptives: Effective for ovulatory dysfunction bleeding. Can be combined with NSAIDs for additional 30-50% reduction. Contraindicated in cardiovascular disease, smoking >35 years, thrombophilia. 1, 5

• Oral progestins (medroxyprogesterone acetate): Administer 21 days per month for cyclic heavy bleeding. Less effective than LNG-IUD but useful when IUD placement fails. 6, 5

When to Proceed Directly to Surgery

If bleeding persists despite 3-6 months of appropriate medical therapy, or if structural lesions requiring removal are identified, surgical intervention is mandatory. 1, 5

Surgical Options in Order of Invasiveness:

1. Hysteroscopic polypectomy/myomectomy: For focal lesions (polyps, submucosal fibroids) identified on imaging. This should have been done before the third curettage if structural pathology was suspected. 7

2. Endometrial ablation: For women with completed childbearing who want uterus preservation. Efficacy comparable to LNG-IUD (71-95% reduction in bleeding). Critical caveat: Obtain thorough informed consent regarding long-term complications including postablation Asherman syndrome, cervical stenosis, and potential delayed endometrial cancer diagnosis. 5

3. Uterine artery embolization: For fibroid-related bleeding when fertility preservation desired. Registry data shows 81-100% clinical success rates, though 20-25% symptom recurrence at 5-7 years. 2

4. Hysterectomy: Definitive treatment with 90% patient satisfaction at 2 years. Indicated when medical management fails, patient has completed childbearing, or concurrent pathology (adenomyosis, large fibroids) exists. 2, 1

Special Clinical Scenarios Requiring Modified Approach

If Patient Has Cardiovascular Disease or Post-SCAD:

• Avoid NSAIDs and tranexamic acid due to MI and thrombosis risk
• LNG-IUD becomes the only safe first-line option due to minimal systemic absorption 1, 5

If Patient on Anticoagulation:

• Reassess need for ongoing anticoagulation
• LNG-IUD is particularly effective (71-95% reduction) with minimal drug interactions 1, 5

If Fibroids Are the Primary Cause:

• GnRH agonists can reduce uterine/myoma volume temporarily but cause trabecular bone loss with chronic use—only use preoperatively 1
• Consider uterine artery embolization for fertility preservation or hysterectomy for definitive treatment 2

Mandatory Workup Before Final Treatment Decision

Since three curettages have already been performed, ensure the following have been completed:

• Imaging: Transvaginal ultrasound with Doppler to assess for UAVM, adenomyosis, fibroids. If inadequate, proceed to saline infusion sonohysterography or MRI. 5, 3

• Hysteroscopy: Direct visualization of endometrial cavity to diagnose focal lesions potentially missed by blind curettage. This has high sensitivity and negative predictive value for intracavitary pathology. 5, 7

• Laboratory: CBC with platelets, TSH, prolactin, coagulation studies (especially von Willebrand disease in adolescents), pregnancy test if reproductive age. 5

Common Pitfalls to Avoid

• Do not perform a fourth curettage unless UAVM has been definitively excluded and you're treating confirmed GTN with surgical intent 2, 3
• Do not rely on endometrial biopsy alone to rule out focal lesions—it has variable sensitivity and misses polyps/submucosal fibroids 5
• Do not delay hysteroscopy if bleeding persists—three failed curettages indicate you're missing something structurally 7