Initial Management of Abnormal Uterine Bleeding

Initial Assessment

• The American College of Radiology recommends a thorough assessment for hemodynamic stability, followed by combined transabdominal and transvaginal ultrasound with Doppler as the first-line imaging study for patients with abnormal uterine bleeding 1, 2
• Urgent evaluation is warranted for patients with bleeding that saturates a large pad or tampon hourly for at least 4 hours, according to the American Heart Association 3, 4
• All reproductive-age women with abnormal uterine bleeding should be tested for pregnancy, as recommended by the American College of Cardiology 3, 4

Diagnostic Approach

• Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study for identifying structural causes of abnormal uterine bleeding, such as polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy, according to the American College of Radiology 1, 2
• Pregnancy test (β-hCG) and thyroid-stimulating hormone and prolactin levels should be performed as part of the diagnostic workup, as recommended by the American Academy of Family Physicians 5, 6

Classification of Abnormal Uterine Bleeding

• The PALM-COEIN Classification System categorizes structural causes of abnormal uterine bleeding as Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, and non-structural causes as Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified, according to the American Academy of Family Physicians 5, 6

Special Considerations

• In patients on antiplatelet therapy with abnormal uterine bleeding, reassess the indication for ongoing antiplatelet therapy and consider discontinuation if appropriate, as recommended by the American Heart Association 3, 4
• Avoid nonsteroidal anti-inflammatory drugs and tranexamic acid in patients with cardiovascular disease due to association with MI and thrombosis, according to the American Heart Association 3, 4

Differential Diagnosis for Abnormal Heavy Menstrual Bleeding

Structural Causes

• Endometrial polyps are common structural sources of abnormal uterine bleeding, particularly in women over 40 years of age 7, 8
• Adenomyosis is a frequent cause in premenopausal women that can be visualized on imaging 7, 8
• Uterine fibroids are the most common structural cause in women under 40 years of age presenting with heavy menstrual bleeding 7, 8
• Endometrial cancer is the most serious etiology and the main focus in postmenopausal women with bleeding; endometrial hyperplasia is also included in this category 7, 8

Non-Structural Causes

• Primary endometrial disorders such as molecular deficiencies in the regulation of endometrial hemostasis can cause heavy menstrual bleeding 7, 8
• Iatrogenic causes, including bleeding from exogenous gonadal steroids, intrauterine devices, and anticoagulation therapy, can result in heavy menstrual bleeding, with approximately 70% of women on anticoagulation experiencing this symptom 7, 8
• Other causes not fitting into the above categories can also contribute to heavy menstrual bleeding 7, 8

Approach to Assessing Abnormal Uterine Bleeding

Risk Factors and Diagnosis

• The American College of Radiology recommends that age, particularly postmenopausal status, obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, and Lynch syndrome or family history of endometrial cancer be considered as risk factors for endometrial cancer 9
• The American College of Radiology suggests that an abdominal examination should be performed to assess for hemodynamic instability and to palpate for an enlarged uterus or masses 9
• The American College of Radiology recommends that a speculum examination be performed to visualize the cervix and vagina and to exclude cervical or vaginal sources of bleeding 9
• The American College of Radiology suggests that a bimanual examination be performed to assess uterine size, contour, mobility, and adnexal masses 9
• Transvaginal ultrasound (TVUS) is the primary imaging modality for evaluating the endometrium and myometrium, with an endometrial thickness of less than 4 mm in postmenopausal women having a nearly 100% negative predictive value for cancer 10
• Saline infusion sonohysterography has a sensitivity of 96-100% and a negative predictive value of 94-100% for uterine and endometrial pathology, and can distinguish between leiomyomas and endometrial polyps with 97% accuracy 11, 10
• MRI pelvis should be considered when ultrasound incompletely visualizes the uterus or findings are indeterminate, with a sensitivity of up to 79% and specificity of up to 89% for endometrial cancer 10

Referral and Treatment

• The American Academy of Family Physicians recommends that patients with failed medical management, endometrial sampling showing hyperplasia or malignancy, or postmenopausal bleeding with endometrial thickness greater than or equal to 4 mm should be referred to a gynecologist 11, 9, 10
• The American College of Radiology suggests that surgical options such as endometrial ablation or hysterectomy should be considered after failed medical management, with hysterectomy providing complete resolution of symptoms and significantly better health-related quality of life compared to other therapies 11

Causes of Menorrhagia

Structural and Non-Structural Causes

• Menorrhagia is caused by structural abnormalities in approximately 50% of cases, with uterine fibroids being the most common cause in women under 40, and endometrial polyps being more common in women over 40, according to the American Academy of Family Physicians 12
• Ovulatory dysfunction, including oligo-ovulation and anovulation, can cause irregular, heavy bleeding and should prompt evaluation for underlying causes, as recommended by the American Academy of Family Physicians 12
• Oral anticoagulants, such as factor Xa inhibitors like rivaroxaban, can cause abnormal uterine bleeding in 9-14% of reproductive-age women, with rivaroxaban associated with prolonged bleeding (>8 days) in 27% of cases, as reported by the European Society of Cardiology 13, 14

Iatrogenic Causes

• Approximately 70% of women on anticoagulation therapy experience heavy menstrual bleeding, with oral anticoagulants being a common cause, as reported by the European Society of Cardiology 13, 14

Levonorgestrel‑Releasing Intrauterine Device (LNG‑IUD) in the Management of Heavy Menstrual Bleeding

Efficacy and Unique Evaluation

• The LNG‑IUD is the only progestin intrauterine device that has been specifically evaluated for treatment of abnormal uterine bleeding, demonstrating high effectiveness in reducing menstrual blood loss. 15

Mechanism of Action

• The device exerts its therapeutic effect primarily at the endometrial level and achieves minimal systemic hormone absorption, making it suitable for patients where systemic exposure is undesirable. 15

Oral Progestin Alternative

• A regimen of oral progestins taken for 21 days each month reduces menstrual blood loss by roughly 87 % in women with cyclic heavy bleeding. 15

Cardiovascular Contraindications

• In patients with cardiovascular disease or a history of spontaneous coronary artery dissection, both NSAIDs and tranexamic acid should be avoided because they increase the risk of myocardial infarction and thrombosis; consequently, the LNG‑IUD is the strongly preferred medical option due to its minimal systemic absorption. 15

Hormonal Therapy in Cardiovascular Patients

• Systemic hormonal therapies (e.g., combined oral contraceptives, oral progestins) are relatively contraindicated in individuals with cardiovascular disease and should be used only after careful clinical judgment. 15

Management of Women on Anticoagulation

• For patients receiving anticoagulant or antiplatelet therapy, progestin‑eluting intrauterine devices are preferred because they provide effective bleeding control while maintaining minimal systemic hormone levels. 15

Avoid Initiating Hormonal Contraception Without Prior Ultrasound in Women With Intermenstrual Bleeding

Clinical Recommendation

• In reproductive‑age women presenting with intermenstrual bleeding, hormonal contraception should not be started before a transvaginal (or combined transvaginal‑abdominal) ultrasound is performed, because initiating therapy first can conceal underlying structural lesions such as polyps, leiomyomas, endometrial hyperplasia, or malignancy. The CDC’s MMWR recommendations (2010) emphasize this precaution. 16