What is the best course of treatment for a woman of reproductive age with no known medical history experiencing abnormal uterine bleeding?

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 without contraindications, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1

Immediate Assessment Required

Before initiating any treatment, three critical steps must be completed:

• Pregnancy test (β-hCG) is mandatory in all reproductive-age women presenting with abnormal uterine bleeding 2, 1
• Assess hemodynamic stability—urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
• Perform combined transabdominal and transvaginal ultrasound with Doppler as first-line imaging 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 2, 1

Diagnostic Framework: PALM-COEIN Classification

The American Academy of Family Physicians recommends categorizing bleeding causes using this system 2, 1:

Structural causes (PALM):

• Polyp (more common in women >40 years) 2
• Adenomyosis (frequent in premenopausal women, often coexists with fibroids) 2, 1
• Leiomyoma/fibroids (most common structural cause in women <40 years) 2
• Malignancy and hyperplasia 2

Non-structural causes (COEIN):

• Coagulopathy 2
• Ovulatory dysfunction (causes irregular, heavy bleeding) 2
• Endometrial disorders 2
• Iatrogenic (anticoagulants cause heavy bleeding in ~70% of women; rivaroxaban causes prolonged bleeding in 27%) 2
• Not yet classified 2

Medical Management Algorithm

First-Line Treatment

Levonorgestrel-releasing IUD (LNG-IUD) is the preferred initial therapy for most patients 1:

• Reduces menstrual blood loss by 71-95% 1
• Efficacy equivalent to endometrial ablation 1
• Minimal systemic absorption makes it suitable even for patients on antiplatelet therapy 1

Alternative Medical Options (in descending order of preference)

Combined hormonal contraceptives (CHCs):

• Effective for ovulatory dysfunction bleeding 1
• Can be combined with NSAIDs to further reduce bleeding volume 1
• Critical caveat: Relatively contraindicated in patients with cardiovascular disease 1

Oral progestins:

• Administer for 21 days per month 1, 3
• Effective for cyclic heavy bleeding related to menstrual cycle 1
• Useful when estrogen-containing products are contraindicated 3

Tranexamic acid:

• High efficacy for heavy menstrual bleeding 1
• Must be avoided in patients with cardiovascular disease due to MI and thrombosis risk 2, 1

NSAIDs:

• Effective when combined with hormonal therapy 1
• Contraindicated in cardiovascular disease 2, 1

Special Population Considerations

Patients with Cardiovascular Disease or Post-SCAD

This population requires modified management 1:

• LNG-IUD becomes the only preferred option due to minimal systemic absorption 1
• Avoid NSAIDs and tranexamic acid (MI and thrombosis risk) 2, 1
• Hormonal therapy is relatively contraindicated despite being first-line for most cases 1

Patients on Antiplatelet or Anticoagulation Therapy

• Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating treatment 1
• Progestin-eluting IUDs are preferred due to minimal systemic absorption 1
• Approximately 70% of women on anticoagulation experience heavy menstrual bleeding 2

When Medical Management Fails

If bleeding persists despite initial medical therapy, proceed with:

Further investigation:

• Hysteroscopy allows direct visualization of endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 1
• 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:

• Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Warning: Endometrial ablation has long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis—thorough informed consent is required 1
• Hysterectomy is the most definitive treatment when medical management fails or is contraindicated, providing complete resolution and significantly better quality of life 2, 1

Mandatory Gynecology Referral Criteria

Refer immediately if 2:

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

Common Pitfalls to Avoid

• Never skip pregnancy testing in reproductive-age women—this is non-negotiable 2, 1
• Do not use NSAIDs or tranexamic acid in patients with cardiovascular disease 2, 1
• Do not rely on endometrial biopsy alone to exclude focal lesions 1
• Ensure proper informed consent before endometrial ablation regarding long-term complications 1
• If transvaginal ultrasound incompletely visualizes the uterus or findings are indeterminate, proceed to MRI pelvis (sensitivity up to 79%, specificity up to 89% for endometrial cancer) 2