Management of Abnormal Uterine Bleeding

Initial Diagnostic Framework

• The American Academy of Family Physicians recommends using the PALM-COEIN classification system to categorize the bleeding cause 1
• The PALM-COEIN classification system includes structural causes such as polyp, adenomyosis, leiomyoma (fibroids), and malignancy and hyperplasia 2, 1
• Non-structural causes include coagulopathy, ovulatory dysfunction, iatrogenic, and not yet classified 2, 1

Medical Management Algorithm

• The American College of Obstetricians and Gynecologists recommends the levonorgestrel-releasing intrauterine device (LNG-IUD) as the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation 2, 3
• The LNG-IUD demonstrates a 71-95% reduction in menstrual blood loss and efficacy equivalent to endometrial ablation 2, 3
• Combined hormonal contraceptives (CHCs) are effective for ovulatory dysfunction bleeding and can be used with NSAIDs to reduce bleeding volume further 2, 1
• Oral progestins can be administered for 21 days per month for menstrual blood loss reduction and are effective for women with cyclic heavy bleeding related to menstrual cycle 2, 3

Surgical Management

• The American College of Obstetricians and Gynecologists recommends endometrial ablation as a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 2, 3, 1
• Hysterectomy is the most appropriate treatment when medical management fails or is contraindicated, particularly in postmenopausal women with symptomatic fibroids 2

Special Clinical Scenarios

• Adenomyosis frequently coexists with fibroids and presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia, commonly affecting women in their 40s 2

Management of Treatment Failure

• If bleeding persists despite initial medical therapy, further investigation with imaging or hysteroscopy is indicated 3, 1
• Hysteroscopy allows visualization of endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 1

Treatment of Abnormal Uterine Bleeding

Initial Assessment and Classification

• Pregnancy testing should be performed in all reproductive-age women, according to the American College of Cardiology, to rule out pregnancy as a cause of abnormal uterine bleeding 4, 5

Medical Management Algorithm

• Transvaginal ultrasonography should be ordered if a structural etiology is suspected or symptoms persist despite treatment, as recommended by the American Academy of Family Physicians 6

Important Caveat for Special Populations

• In women with cardiovascular disease or post-SCAD, NSAIDs and tranexamic acid should be avoided due to the risk of MI and thrombosis, and the levonorgestrel-releasing IUD becomes the preferred option, as suggested by the American Heart Association 4, 5

Surgical Management

• If bleeding persists despite medical therapy, further investigation using hysteroscopy should be performed to diagnose focal lesions potentially missed by endometrial sampling, as recommended by the American Academy of Family Physicians 6

Common Pitfalls to Avoid

• Endometrial biopsy alone should not be used to rule out focal lesions, as it has variable sensitivity, and saline infusion sonohysterography has high sensitivity and negative predictive value for assessing intracavitary pathology, according to the American Academy of Family Physicians 6
• Endometrial ablation has long-term complications, including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis, and thorough informed consent should be provided, as recommended by the American Academy of Family Physicians 6

Treatment of Abnormal Uterine Bleeding with Medical Management

Initial Treatment Options

• The American College of Cardiology recommends avoiding NSAIDs and tranexamic acid in patients with cardiovascular disease or post-SCAD due to the risk of MI and thrombosis, making the levonorgestrel-releasing IUD the preferred option in this population 7
• For patients on antiplatelet therapy, reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating AUB treatment, with progestin-eluting IUDs preferred due to minimal systemic absorption 7
• Hysterectomy is the definitive treatment when medical management fails or is contraindicated, and can be considered for patients who have completed childbearing and desire permanent resolution 8

Special Considerations

• In patients with cardiovascular disease or post-SCAD, hormonal therapy is relatively contraindicated, despite being first-line for most AUB cases, and careful clinical judgment and consideration of progestin-only IUDs is required 7

Management of Abnormal Uterine Bleeding

Evidence-Based Treatment Options

• The American College of Obstetricians and Gynecologists and American College of Radiology do not recommend ascorbic acid for abnormal uterine bleeding, and instead suggest established first-line medical treatments 9, 10

Diagnostic Considerations

• The American College of Radiology recommends pregnancy testing, combined transabdominal and transvaginal ultrasound with Doppler, thyroid-stimulating hormone and prolactin levels, and complete blood count with platelets before initiating treatment 9, 10

Treatment Guidelines

• The American Academy of Family Physicians and American College of Obstetricians and Gynecologists suggest that tranexamic acid is a viable option for heavy menstrual bleeding with high efficacy 9, 10
• The American College of Radiology suggests that in patients with cardiovascular disease, the levonorgestrel-releasing IUD becomes the preferred option due to MI and thrombosis risk associated with NSAIDs and tranexamic acid 9, 10

Medical Management of Abnormal Uterine Bleeding

Oral Cyclic Progestins

• Cyclic oral progestin therapy administered for 21 days each month reduces menstrual blood loss by approximately 87 % in women with heavy cyclic bleeding, providing an effective first‑line option for abnormal uterine bleeding. 11

Levonorgestrel‑Releasing Intrauterine System (LNG‑IUS)

• A levonorgestrel‑releasing intrauterine system delivering 20 µg/day decreases menstrual blood loss by 71–95 %, achieving efficacy comparable to endometrial ablation for the treatment of abnormal uterine bleeding. 11
• The LNG‑IUS is the only intrauterine device containing a progestogen that has been specifically evaluated for managing abnormal uterine bleeding. 11

Cardiovascular Safety Considerations

• In patients with cardiovascular disease or a history of spontaneous coronary artery dissection, systemic hormonal therapy is relatively contraindicated and should be used only after careful clinical judgment. 11
• For these high‑risk patients, the LNG‑IUS is preferred because it provides minimal systemic absorption and exerts its effect primarily at the endometrial level. 11
• Non‑steroidal anti‑inflammatory drugs (NSAIDs) and tranexamic acid should be avoided in individuals with cardiovascular disease due to an increased risk of myocardial infarction and thrombosis. 11

Contraception and Ovulation Monitoring

• When prescribing progestogen therapy for conditions such as fibroids, clinicians should assess the need for non‑hormonal contraception because ovulation may still occur in up to 20 % of patients despite treatment. 12
• If abnormal uterine bleeding does not improve during progestogen therapy, a systematic investigation for alternative etiologies should be undertaken. 12

Risks of Endometrial Ablation in Women Who Desire Future Fertility

Surgical Management – Contraindications

• Endometrial ablation carries a high risk of pregnancy‑related complications and therefore should never be performed in women who wish to preserve fertility, as highlighted by evidence published in the Journal of the American College of Radiology 2024 13.

Hormonal Contraceptives as Primary Iatrogenic Cause of Shortened Menstrual Bleeding (< 4 days)

Iatrogenic/Medication‑Related Causes

• In reproductive‑age women, use of hormonal contraceptives—particularly progestin‑only methods (pills, depot medroxyprogesterone acetate, implants) and combined hormonal contraceptives—most frequently results in menstrual bleeding lasting fewer than four days by thinning the endometrial lining and reducing menstrual flow, as reported in the CDC MMWR Recommendations and Reports. [14][15]