What is the appropriate management for a female patient of reproductive age presenting with abnormal uterine bleeding during menstruation?

Management of Abnormal Uterine Bleeding During Menstruation

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for abnormal uterine bleeding, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1

Immediate Assessment and Stabilization

Check hemodynamic stability first - urgent evaluation is warranted if bleeding saturates a large pad or tampon hourly for at least 4 hours. 2, 3

Perform a focused physical examination:

• Speculum examination to visualize the cervix and vagina, excluding cervical or vaginal sources of bleeding 2, 3
• Bimanual examination to assess uterine size, contour, mobility, and adnexal masses 2, 3
• Abdominal palpation for an enlarged uterus or masses 2, 3

Essential Diagnostic Workup

Mandatory Laboratory Tests

• Pregnancy test (β-hCG) in ALL reproductive-age women - this is non-negotiable even in perimenopausal women 2, 1, 3
• Thyroid-stimulating hormone (TSH) levels 2, 3
• Prolactin levels to evaluate for hyperprolactinemia causing ovulatory dysfunction 2, 3
• Complete blood count with platelets before initiating treatment 1

First-Line Imaging

Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study for identifying structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy. 4, 2, 3

Advanced Imaging When Initial Ultrasound is Inconclusive

Saline infusion sonohysterography (SIS) should be performed when initial ultrasound findings are unclear or suggest intracavitary lesions, with sensitivity of 96-100% and negative predictive value of 94-100% for uterine and endometrial pathology. 2, 3 SIS can distinguish between leiomyomas and endometrial polyps with 97% accuracy. 2, 3

MRI pelvis without and with IV contrast is usually appropriate for follow-up imaging when the original ultrasound is inconclusive or further characterization is needed. 4

Classification Framework

Use the PALM-COEIN classification system to categorize the bleeding cause: 2, 1

Structural causes (PALM):

• Polyp - common in women over 40 years 2
• Adenomyosis - frequent cause in premenopausal women, commonly affecting women in their 40s 2, 1
• Leiomyoma (fibroids) - most common structural cause in women under 40 years 2
• Malignancy and hyperplasia - the most serious etiology, main focus in postmenopausal women 2

Non-structural causes (COEIN):

• Coagulopathy - von Willebrand disease is most common 2
• Ovulatory dysfunction - including oligo-ovulation and anovulation 2
• Endometrial - primary endometrial disorders with molecular deficiencies 2
• Iatrogenic - approximately 70% of women on anticoagulation experience heavy menstrual bleeding; oral anticoagulants cause abnormal bleeding in 9-14% of reproductive-age women 2
• Not yet classified 2

Medical Management Algorithm

First-Line Treatment

Levonorgestrel-releasing intrauterine device (LNG-IUD) reduces menstrual blood loss by 71-95% with efficacy equivalent to endometrial ablation. 1 This is the most effective first-line option.

Alternative Medical Options (in descending order of preference)

Combined hormonal contraceptives (CHCs):

• Effective for ovulatory dysfunction bleeding 1
• Can be used with NSAIDs to reduce bleeding volume further 1
• Contraindicated in women with cardiovascular disease 1

Oral progestins:

• Administer for 21 days per month for menstrual blood loss reduction 1
• Effective for women with cyclic heavy bleeding related to menstrual cycle 1
• Preferred in patients on antiplatelet therapy due to minimal systemic absorption 1

Tranexamic acid:

• Viable option for heavy menstrual bleeding with high efficacy 1, 5
• AVOID in patients with cardiovascular disease or post-SCAD due to risk of MI and thrombosis 2, 1

NSAIDs (e.g., ibuprofen):

• May be utilized with hormonal methods to decrease menstrual bleeding 5
• AVOID in patients with cardiovascular disease due to association with MI and thrombosis 2, 1

Special Clinical Scenarios

Patients with Cardiovascular Disease or Post-SCAD

The levonorgestrel-releasing IUD becomes the preferred option because NSAIDs and tranexamic acid are contraindicated due to MI and thrombosis risk. 2, 1 Hormonal therapy is relatively contraindicated despite being first-line for most AUB cases. 1

Patients on Antiplatelet Therapy

Reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating AUB treatment. 2 Progestin-eluting IUDs are preferred due to minimal systemic absorption. 1

Patients on Anticoagulation Therapy

Approximately 70% experience heavy menstrual bleeding. 2 Consider progestin-only methods and gonadotropin-releasing hormone agonists. 5

Endometrial Sampling Indications

Perform endometrial biopsy in:

• Women ≥35 years with recurrent anovulation 6
• Women <35 years with risk factors for endometrial cancer 6
• Women with excessive bleeding unresponsive to medical therapy 6
• Perimenopausal women with risk factors: obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, Lynch syndrome or family history of endometrial cancer 2, 3

Critical caveat: Endometrial biopsy alone should not be used to rule out focal lesions as it has variable sensitivity. 1

When Medical Management Fails

If bleeding persists despite initial medical therapy:

1. Hysteroscopy allows direct visualization of the endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 1, 3
2. Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
3. Hysterectomy is the most appropriate treatment when medical management fails or is contraindicated, providing complete resolution of symptoms and significantly better health-related quality of life 2, 1

Referral to Gynecology

Refer when:

• Failed medical management occurs 2, 3
• Endometrial sampling shows hyperplasia or malignancy 2
• Postmenopausal bleeding with endometrial thickness ≥4 mm 2, 3
• Endometrial thickness ≥4 mm with persistent bleeding 3

Common Pitfalls to Avoid

• Never skip pregnancy testing, even in perimenopausal women 3
• Do not rely on transabdominal ultrasound alone in non-virgins - transvaginal approach provides superior endometrial assessment 3
• Do not perform routine endometrial biopsy in all perimenopausal women - target those with risk factors for endometrial cancer or failed medical management 3
• Do not miss cervical or vaginal sources - always perform speculum examination before attributing bleeding to uterine causes 3
• Endometrial ablation has long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis - provide thorough informed consent 1