Abnormal Uterine Bleeding

Background

• Abnormal uterine bleeding refers to bleeding originating from the uterus that is of an abnormal volume, frequency, or duration, and includes acute severe or prolonged uterine bleeding and chronic heavy menstrual bleeding.
• About 14%-40% of patients of childbearing age are reported to have abnormal uterine bleeding. Causes include:
  • structural uterine abnormalities, such as, endometrial polyps, uterine fibroids, adenomyosis, or malignancy
  • early pregnancy-related complications, including spontaneous abortion, septic abortion, or ectopic pregnancy
  • coagulopathies or bleeding disorders
  • ovulatory dysfunction, including polycystic ovarian syndrome or other causes of oligoovulation, such as eating disorders or physical or psychological stress
  • smoking
  • iatrogenic sources, such as, medications or breakthrough bleeding with use of intrauterine device or noncompliance with hormonal contraceptives
  • sexually transmitted infection
  • sexual trauma

Evaluation

• The initial evaluation of patients presenting with abnormal uterine bleeding should include (Strong recommendation):
  • patient age
  • complete menstrual history, including
    • age of menarche
    • age of menopause (if applicable)
    • bleeding pattern, including intensity, duration, and frequency of bleeding, as well as any associated symptoms
  • review of medical comorbidities and medications
  • physical examination, including vital signs
  • pregnancy test
  • complete blood count if patient has a history of excessive blood loss
  • endometrial sampling to exclude malignancy in patients ≥ 45 years old or who have risk factors for endometrial malignancy
  • pelvic ultrasound, particularly in patients with an abnormal pelvic exam or in whom polycystic ovarian disorder is suspected
• Additional testing is guided by patient history, physical examination, and response to treatment, and may include thyroid-stimulating hormone (TSH), coagulation studies, endometrial sampling to exclude malignancy, pelvic ultrasound, saline infusion sonography, and/or hysteroscopy (Strong recommendation).

Management

• Treatment for severe acute or prolonged abnormal uterine bleeding:
  • For patients with hemodynamic instability or who have signs of hypovolemia, initiate IV access with a single or 2 large bore IV lines and prepare for blood transfusion and clotting factor replacements.
  • Medical treatment options include:
    • conjugated estrogen 25 mg IV every 4-6 hours for 24 hours
    • monophasic combined oral contraceptives that includes ethinyl estradiol 35 mcg orally up to 3 times daily for up to 7 days
    • medroxyprogesterone acetate 20 mg orally up to 3 times daily for up to 7 days
    • tranexamic acid 1,300 mg orally 3 times daily or 10 mg/kg (maximum 600 mg/dose) IV every 8 hours for 5 days
  • Patients with known or suspected bleeding disorders, such as von Willebrand disease, hemophilia, and disseminated intravascular coagulation, may need the addition of specific factor replacement; consultation with patient's hematologist is suggested.
  • Procedural interventions may be considered for patients who
    • are not clinically stable
    • are not suitable for medical management
    • have failed to respond to medical management
  • Factors affecting choice of procedure include
    • underlying medical conditions
    • underlying pathology
    • desire for future fertility
  • Options include:
    • intrauterine (endometrial) balloon tamponade
    • endometrial ablation
    • uterine artery embolization
    • dilation and curettage
    • hysterectomy
• Treatment for patients with anovulatory bleeding:
  • Medical management is recommended for anovulatory bleeding (Strong recommendation).
  • Hormonal treatment regimens include (Strong recommendation):
    • insertion of levonorgestrel-releasing intrauterine system (LNG-IUS)
    • combined oral contraceptive that includes ethinyl estradiol ≤ 35 mcg
    • high-dose oral progestins, such as, medroxyprogesterone acetate (Provera) 10 mg/day for 10-14 days per month
  • Nonhormonal treatment options include correction of the underlying endocrinopathy with metformin and other insulin-sensitizing drugs in patients with polycystic ovary syndrome, or thyroid medications in patients with abnormal thyroid function.
  • Surgery may be indicated for anovulatory uterine bleeding in patients with atypia or malignancy or abnormal bleeding due to structural malformations (Strong recommendation). Surgery is rarely necessary for patients with anovulatory bleeding (Strong recommendation).
• Treatment for patients with abnormal bleeding in the context of ovulatory cycles and normal results on imaging:
  • Initial treatment is with medical management.
  • Hormonal treatment regimens include:
    • combined oral contraceptive that includes ethinyl estradiol < 35 mcg
    • medroxyprogesterone acetate 10 mg/day for 21 days per month for 3-6 months
    • insertion of levonorgestrel-releasing intrauterine system (LNG-IUS)
  • Nonhormonal treatment regimens include:
    • trial of nonsteroidal anti-inflammatory drug (NSAIDs) beginning first day of menses and continuing until menses cease
    • tranexamic acid 1,300 mg (2 tablets) orally 3 times daily on days 1-5 of cycle
  • If excessive bleeding continues after a 3- to 6-month trial of pharmacological therapy, consider endometrial biopsy and/or referral for possible hysteroscopy, endometrial ablation, or hysterectomy (Strong recommendation).