Hormonal Management of Abnormal Uterine Bleeding

1. Diagnostic Prerequisites Before Initiating Hormonal Therapy

Prior to starting any hormonal treatment, clinicians should confirm the diagnosis of abnormal uterine bleeding and exclude structural or systemic causes such as endometrial malignancy, hyperplasia, polyps, fibroids requiring intervention, coagulopathy, thyroid disorders, and pregnancy. – American College of Obstetricians and Gynecologists (ACOG) 1; Centers for Disease Control and Prevention (CDC) 2

2. First‑Line Hormonal Treatment Options

The ACOG recommends combined hormonal contraceptives (CHCs) — including pills, patches, or vaginal rings — or progestin‑only contraception — including pills, depot medroxyprogesterone acetate (DMPA), implants, or levonorgestrel intrauterine system (LNG‑IUS) — as first‑line medical therapy for abnormal uterine bleeding associated with ovulatory dysfunction. – ACOG 1

If the LNG‑IUS is contraindicated or declined, alternative first‑line options include combined oral contraceptives (standard or extended/continuous regimens), progestin‑only pills, DMPA injections, and etonogestrel implants. – ACOG 1

3. Management of Breakthrough or Persistent Bleeding

3.1 Implant Users (Heavy/Prolonged Bleeding)

3.2 DMPA Users (Spotting/Light Bleeding)

3.3 Copper IUD Users (Any Bleeding Pattern)

3.4 LNG‑IUS Users

4. Hormone‑Free Interval Guidance for Extended/Continuous CHC Regimens

Do not introduce hormone‑free intervals during the first 21 days of an extended or continuous combined hormonal contraceptive regimen, as this may reduce contraceptive efficacy. If a hormone‑free interval is desired after day 21, limit it to a maximum of one interval per month. – CDC [2][3]

5. Indications for Surgical Intervention When Medical Management Fails

If hormonal therapy is ineffective, contraindicated, not tolerated, or if significant intracavitary lesions (e.g., large polyps or fibroids) are present, surgical options such as endometrial ablation or hysterectomy should be considered. – ACOG 1

Management of Persistent Spotting and Device Retention in Mirena Users

Diagnostic Exclusion

• Clinicians should first exclude pelvic infection as a potential cause of abnormal uterine bleeding in patients using the Mirena intra‑uterine system. This recommendation applies to women presenting with intermittent spotting or other bleeding changes and is based on guidance from American Family Physician (2015) (expert opinion) 4.

Criteria for Device Removal

• When spotting remains bothersome despite counseling and a trial of non‑steroidal anti‑inflammatory drugs, the patient should be counseled about switching to an alternative contraceptive method. This applies to Mirena users whose irregular bleeding persists beyond the expected adaptation period (≥ 6 months) and is supported by American Family Physician (2015) (expert opinion) 4.