How should a 39-year-old woman with continuous abnormal uterine bleeding for 12 days be evaluated and managed?

Management of 12-Day Continuous Abnormal Uterine Bleeding in a 39-Year-Old Woman

This patient requires urgent evaluation for hemodynamic stability followed by immediate pregnancy testing, combined transabdominal and transvaginal ultrasound with Doppler, and initiation of medical management with either a levonorgestrel-releasing IUD, combined hormonal contraceptives, or tranexamic acid based on her medical history and contraindications. 1

Immediate Assessment Required

Assess hemodynamic stability first - bleeding saturating a large pad or tampon hourly for at least 4 hours warrants urgent evaluation. 1 At 12 days of continuous bleeding, this patient needs prompt assessment for signs of hypovolemia including:

• Vital signs for tachycardia and hypotension 2
• Hemoglobin and iron levels to assess for anemia 1, 3
• Physical examination including abdominal palpation for enlarged uterus or masses 1

Essential Diagnostic Workup

All reproductive-age women must have pregnancy testing (β-hCG) before proceeding - this is non-negotiable regardless of contraceptive use or reported sexual history. 1, 4

Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study and should be performed to identify structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy. 1 This imaging modality has 96-100% sensitivity and 94-100% negative predictive value for uterine and endometrial pathology. 1

Additional laboratory testing should include:

• Complete blood count with platelets 1
• Thyroid-stimulating hormone (TSH) 1, 4
• Prolactin levels 1, 4
• Coagulation studies if bleeding disorder suspected 5

Perform speculum examination to visualize the cervix and vagina, excluding cervical or vaginal sources of bleeding, and bimanual examination to assess uterine size, contour, mobility, and adnexal masses. 1

Classification Using PALM-COEIN System

Use this framework to categorize the bleeding cause: 1, 6

Structural causes (PALM):

• Polyp - more common in women over 40 1
• Adenomyosis - frequent in premenopausal women, often coexists with fibroids 6
• Leiomyoma - most common structural cause in women under 40 1
• Malignancy/hyperplasia - assess risk factors including obesity, diabetes, hypertension, unopposed estrogen exposure 1

Non-structural causes (COEIN):

• Coagulopathy - consider if heavy bleeding since menarche 5
• Ovulatory dysfunction - common cause of irregular heavy bleeding 1
• Endometrial - primary endometrial disorders 1
• Iatrogenic - anticoagulation (70% experience heavy bleeding), IUDs, hormonal medications 1
• Not yet classified 1

Medical Management Algorithm

Once structural causes requiring surgery are excluded, medical management is first-line treatment. 5, 2

First-Line Options (Choose Based on Patient Factors):

Levonorgestrel-releasing IUD (LNG-IUD) - the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 6 This is particularly preferred in patients with cardiovascular disease where NSAIDs and tranexamic acid should be avoided due to MI and thrombosis risk. 1, 6

Combined hormonal contraceptives (CHCs) - effective for ovulatory dysfunction bleeding and can be used with NSAIDs to reduce bleeding volume further. 6 For acute bleeding control, multidose regimens can be used. 2

Tranexamic acid - highly effective for heavy menstrual bleeding but should be avoided in patients with cardiovascular disease or thrombosis risk. 1, 6, 5

Oral progestins - can be administered for 21 days per month for menstrual blood loss reduction, effective for cyclic heavy bleeding. 6 Multidose regimens are also viable for acute bleeding. 2

Critical Contraindications to Avoid:

• Do NOT use NSAIDs or tranexamic acid in patients with cardiovascular disease due to association with MI and thrombosis. 1, 6
• Reassess antiplatelet therapy indication if patient is on these medications and consider discontinuation if appropriate. 1
• Hormonal therapy is relatively contraindicated in cardiovascular disease patients, making progestin-only IUDs the preferred option. 6

When to Escalate Care

Refer to gynecology if: 1

• Failed medical management after appropriate trial
• Endometrial sampling shows hyperplasia or malignancy
• Bleeding persists despite initial medical therapy - further investigation with hysteroscopy is indicated 6
• Patient is not clinically stable or hemodynamically unstable 2

Surgical options include:

• Endometrial ablation - less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 6
• Hysteroscopic removal of focal lesions (polyps, submucous fibroids) 4, 3
• Hysterectomy - definitive treatment when medical management fails or is contraindicated, providing complete resolution 1, 6

Common Pitfalls to Avoid

Do not rely on endometrial biopsy alone to rule out focal lesions - it has variable sensitivity. Saline infusion sonohysterography has superior sensitivity (96-100%) for detecting intracavitary pathology. 1, 6

Do not delay pregnancy testing - this must be performed before any other intervention in all reproductive-age women. 1, 4

Do not use ascorbic acid - it is not recommended by ACOG or ACR for abnormal uterine bleeding treatment. 6

Ensure informed consent for endometrial ablation regarding long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis. 6