What is the initial evaluation and management for a woman in her 40s with dysfunctional uterine bleeding?

Management of Dysfunctional Uterine Bleeding in a Woman in Her 40s

For a woman in her 40s with dysfunctional uterine bleeding, start with a levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line medical therapy after ruling out pregnancy and structural causes with transvaginal ultrasound. 1, 2

Initial Evaluation

Immediate Assessment

• Rule out pregnancy first with β-hCG testing in all reproductive-age women, regardless of contraceptive use or perceived pregnancy risk 1, 2
• Assess hemodynamic stability—urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 1
• Perform speculum examination to exclude cervical or vaginal bleeding sources 1

Diagnostic Workup

• Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study to identify structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1
• Obtain thyroid-stimulating hormone and prolactin levels to evaluate for endocrine causes 1
• Complete blood count with platelets to assess for anemia and coagulopathy 2
• Consider endometrial sampling in women over 45 years or those with risk factors for endometrial cancer (obesity, diabetes, hypertension, unopposed estrogen exposure, Lynch syndrome) 1

Classification Using PALM-COEIN

• Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia 1, 3
• Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 1, 3
• Women in their 40s commonly have ovulatory dysfunction due to perimenopause, but structural causes must be excluded 3

Medical Management Algorithm

First-Line Therapy

• Levonorgestrel-releasing IUD (LNG-IUD) is the most effective medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation 2, 3
• The LNG-IUD should be strongly considered as first-line therapy for women desiring uterus preservation 3

Alternative First-Line Options

• Combined oral contraceptives are effective for ovulatory dysfunction bleeding and can be used with NSAIDs to further reduce bleeding volume 2
• For non-smokers without cardiovascular disease, low-dose combination oral contraceptives are appropriate in perimenopausal women 4, 5
• Oral progestins administered for 21 days per month reduce menstrual blood loss and are effective for cyclic heavy bleeding 2
• Tranexamic acid is a non-hormonal alternative reducing menstrual blood loss by 20-60%, particularly useful for patients who cannot use hormonal therapy 2, 3
• NSAIDs reduce menstrual bleeding and can be combined with hormonal methods 2, 6

Second-Line Therapy (If First-Line Fails)

• Add tranexamic acid to combined oral contraceptive if bleeding persists on COCP alone 7
• Consider discontinuing COCP and inserting an IUD if combination therapy fails 7
• COCP combined with DDAVP may be considered in select cases 7

Third-Line Therapy

• Combined DDAVP/COCP/TXA regimen for refractory cases 7
• GnRH agonists or antagonists (elagolix, linzagolix, relugolix) can reduce bleeding symptoms and fibroid volume if present 3

Important Caveats and Special Considerations

Cardiovascular Disease

• Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease or post-SCAD due to MI and thrombosis risk 1, 2
• In these patients, the levonorgestrel-releasing IUD becomes the preferred option due to minimal systemic absorption 2

Anticoagulation Therapy

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

Adenomyosis Consideration

• Adenomyosis frequently coexists with fibroids in women in their 40s, presenting with heavy menstrual bleeding, dysmenorrhea, and dyspareunia 2, 3
• This diagnosis should be considered when evaluating imaging findings 2

When to Refer to Gynecology

• Failed medical management after appropriate trial 1
• Endometrial sampling showing hyperplasia or malignancy 1
• Endometrial thickness ≥4 mm on ultrasound with persistent bleeding 1
• Persistent bleeding despite medical therapy requiring hysteroscopy to diagnose focal lesions potentially missed by endometrial sampling 2

Surgical Options (After Medical Management Failure)

• Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 2
• Hysterectomy provides definitive resolution of symptoms and significantly better health-related quality of life compared to other therapies, particularly when medical management fails or is contraindicated 1, 2, 3
• Choose the least invasive surgical route (vaginal > laparoscopic/robotic > abdominal) based on uterine size and surgical expertise 3

Common Pitfalls to Avoid

• Do not rely on endometrial biopsy alone to rule out focal lesions—saline infusion sonohysterography has high sensitivity (96-100%) and negative predictive value (94-100%) for uterine and endometrial pathology 1
• Do not prescribe NSAIDs or tranexamic acid to women with cardiovascular disease without considering the thrombotic risk 1, 2
• Do not skip pregnancy testing even in women using contraception or with irregular cycles 1, 2
• Endometrial ablation has long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis—provide thorough informed consent 2