From the Guidelines
The treatment approach to abnormal uterine bleeding (AUB) should prioritize identifying and addressing the underlying cause while managing symptoms, with initial management including hormonal therapies such as combined hormonal contraceptives or progestin-only options, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1.
Key Considerations
- The PALM-COEIN classification system, developed by ACOG, is used to describe uterine bleeding abnormalities in women of reproductive age, including structural causes (polyp, adenomyosis, leiomyoma, and malignancy and hyperplasia) and nonstructural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) 1.
- Medical treatments for AUB associated with ovulatory dysfunction include progestin-only contraception and combined hormonal contraception, with the goal of reducing bleeding by stabilizing the endometrium 1.
- If medical treatment fails, is contraindicated, or is not tolerated, or if the patient has concomitant significant intracavitary lesions, surgery, including endometrial ablation and hysterectomy, may be an option 1.
Treatment Options
- Hormonal therapies, such as combined hormonal contraceptives (estrogen-progestin pills, patch, or ring) or progestin-only options (oral medroxyprogesterone acetate, levonorgestrel-releasing intrauterine system, or depot medroxyprogesterone acetate), can be effective in reducing bleeding 1.
- Non-hormonal options, such as NSAIDs (ibuprofen) or tranexamic acid, can be used to reduce prostaglandin-mediated blood loss or for acute heavy bleeding 1.
- Surgical interventions, such as hysteroscopic polypectomy, myomectomy, endometrial ablation, or hysterectomy, may be necessary for patients with structural abnormalities like fibroids or polyps 1.
Patient-Centered Care
- Treatment selection should depend on the specific cause of AUB, the patient's age, desire for fertility, comorbidities, and preferences, with the goal of controlling bleeding, preventing anemia, improving quality of life, and addressing any underlying pathology 1.
- Iron supplementation is important for patients with anemia, and counseling on alternative contraceptive methods or treatment options should be provided if heavy or prolonged bleeding persists and the woman finds it unacceptable 1.
From the FDA Drug Label
For treatment of abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology: One 25 mg injection, intravenously or intramuscularly. Repeat in 6 to 12 hours if necessary 2. 5 to 10 mg norethindrone acetate tablets may be given daily for 5 to 10 days to produce secretory transformation of an endometrium that has been adequately primed with either endogenous or exogenous estrogen.
The treatment approach to abnormal uterine bleeding includes:
- Hormone therapy: using medications such as norethindrone acetate (PO) 2 or conjugated estrogens (IV) 3 3 to regulate hormonal imbalance.
- Dosage: 2.5 to 10 mg of norethindrone acetate tablets daily for 5 to 10 days, or one 25 mg injection of conjugated estrogens intravenously or intramuscularly, repeated in 6 to 12 hours if necessary.
- Treatment duration: short-term use only for conjugated estrogens (IV) 3, or until annoying breakthrough bleeding demands temporary termination for norethindrone acetate (PO) 2.
From the Research
Treatment Approach to Abnormal Uterine Bleeding
The treatment approach to abnormal uterine bleeding (AUB) involves a combination of medical and surgical management. The initial evaluation of the patient should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability 4.
Medical Management
Medical management is the first-line approach for treating AUB, and the choice of treatment depends on the patient's medical history, underlying pathology, and desire for future fertility 4, 5. Options for medical management include:
- Intravenous conjugated equine estrogen
- Multi-dose regimens of combined oral contraceptives or oral progestins
- Tranexamic acid
- Levonorgestrel-releasing intrauterine system (LNG-IUS)
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Gonadotropin-releasing hormone (GnRH) agonists
Surgical Management
Surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management 4. The choice of surgical management depends on the patient's underlying medical conditions, underlying pathology, and desire for future fertility. Options for surgical management include:
- Endometrial ablation
- Hysterectomy
- Ambulatory hysteroscopy (AH)
Comparison of Treatment Options
Studies have compared the effectiveness of different treatment options for AUB. For example, a study compared the LNG-IUS with endometrial ablation for heavy menstrual bleeding and found that both treatments led to a large decrease in menstrual blood loss, but endometrial ablation was more effective in reducing menstrual blood loss 6. Another study found that the LNG-IUS was an effective treatment option for women with heavy menstrual bleeding, including those with underlying organic pathology or bleeding disorders 7.
Role of Ambulatory Hysteroscopy
Ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage AUB, allowing for thorough evaluation of the uterine cavity in an outpatient setting 8. AH can be used to diagnose and treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding, and postmenopausal bleeding.
Considerations for Treatment
When choosing a treatment option, considerations should include the patient's medical history, underlying pathology, and desire for future fertility 4, 5. The patient's quality of life and satisfaction with treatment should also be taken into account 6.