Management of Abnormal Uterine Bleeding

Initial Assessment and Testing

• The American College of Cardiology recommends that all reproductive-age women with abnormal uterine bleeding must be tested for pregnancy and have a complete blood count (CBC) to quantify anemia severity before any intervention 1, 2
• The American Heart Association suggests that symptoms of drowsiness, easy fatigue, and syncope strongly suggest severe anemia requiring immediate quantification, and hemoglobin levels will determine whether the patient needs urgent transfusion, hospitalization, or can be managed outpatient 1, 2
• Patients with hemodynamic instability or severe anemia may require blood transfusion before any other intervention, according to the American College of Cardiology 3

Critical Next Steps After Initial Testing

• If pregnancy test is positive, urgent obstetric consultation for pregnancy-related bleeding complications is necessary, as recommended by the American Heart Association 1
• If hemoglobin <7 g/dL with ongoing bleeding, immediate blood transfusion to maintain hemoglobin ≥7 g/dL is required, according to the Journal of the American College of Cardiology 3
• The American College of Cardiology recommends gynecologic consultation for bleeding control (may require hormonal therapy or surgical intervention) and consideration of high-dose progestin therapy for acute bleeding control 1, 2

Management of Anemia

• For patients with hemoglobin 7-10 g/dL, the American College of Cardiology suggests initiating oral iron supplementation (ferrous sulfate 200 mg once daily) and hormonal therapy to control bleeding (combined oral contraceptives or levonorgestrel IUD) 1, 5
• For patients with hemoglobin >10 g/dL, outpatient workup with ultrasound and possible endometrial sampling, as well as oral iron supplementation and hormonal therapy as needed, is recommended by the American Heart Association 4, 5

Common Pitfalls to Avoid

• The American College of Cardiology advises never delaying pregnancy testing in any reproductive-age woman with abnormal bleeding, regardless of contraceptive use or sexual history 1, 2
• The American Heart Association recommends never performing invasive procedures (D&C, endometrial biopsy, hysteroscopy) before confirming pregnancy status and assessing anemia severity 1