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Abnormal (Dysfunctional) Uterine Bleeding Treatment & Management

  • Author: Millie A Behera, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
 
Updated: Nov 15, 2015
 

Approach Considerations

In July 2013, The American College of Obstetricians and Gynecologists  issued updated guidelines for the treatment of abnormal uterine bleeding caused by ovulatory dysfunction. They included the following recommendations[6] [7] :

  • Surgery should be considered only in patients in whom medical treatment has failed, cannot be tolerated, or is contraindicated
  • Endometrial ablation is not acceptable as a primary therapy, because the procedure can hamper the later use of other common methods for monitoring the endometrium
  • Regardless of patient age, progestin therapy with the levonorgestrel intrauterine device should be considered; contraceptives containing a combination of estrogen and progesterone also provide effective treatment
  • Low-dose combination hormonal contraceptive therapy (20-35 μg ethinyl estradiol) is the mainstay of treatment for adolescents up to age 18 years
  • Either low-dose combination hormonal contraceptive treatment or progestin therapy is generally effective in women aged 19-39 years; high-dose estrogen therapy may benefit patients with an extremely heavy menstrual flow or hemodynamic instability
  • Medical treatment for women aged 40 years or older can, prior to menopause, consist of cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device, or cyclic hormone therapy
  • If medical therapy fails, patients should undergo further testing (eg, imaging or hysteroscopy)
  • An in-office endometrial biopsy is preferable to dilation and curettage (D&C) when examining a patient for endometrial hyperplasia or cancer
  • If medical therapy fails in a woman in whom childbearing is complete, hysterectomy without cervical preservation may be considered
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Medical Care

Options for medical care of abnormal uterine bleeding (AUB) usually involve various protocols of estrogen or progesterone supplementation, yet there is no clear consensus on which exact regimen is most effective.[8] Medical therapy options are discussed below.

Oral contraceptives

Oral contraceptive pills (OCPs) suppress endometrial development, reestablish predictable bleeding patterns, decrease menstrual flow, and lower the risk of iron deficiency anemia.

OCPs can be used effectively in a cyclic or continuous regimen to control abnormal bleeding.

Acute episodes of heavy bleeding suggest an environment of prolonged estrogenic exposure and buildup of the lining. Bleeding usually is controlled within the first 24 hours, as the overgrown endometrium becomes pseudodecidualized. Seek alternate diagnosis if flow fails to abate in 24 hours.

The type of OCP and underlying patient factors may be important determinants of potential risk for complications associated with OCPs. Studies have shown an increased risk of nonfatal venous thromboembolic events (blood clots) associated with contraceptives that contain drospirenone as compared with those that contain levonorgestrel.[9]

Levonorgestrel-releasing intrauterine system is considered a first-line treatment for adolescents with heavy menstrual bleeding.[7, 3]

Estrogen

Estrogen alone, in high doses, is indicated in certain clinical situations.

Prolonged uterine bleeding suggests the epithelial lining of the cavity has become denuded over time. In this setting, a progestin is unlikely to control bleeding. Estrogen alone will induce return to normal endometrial growth rapidly.

Hemorrhagic uterine bleeding requires high-dose estrogen therapy. If bleeding is not controlled within 12-24 hours, a D&C is indicated.

Beginning progestin therapy shortly after initiating estrogen therapy to prevent a subsequent bleeding episode from treatment with prolonged unopposed estrogen is wise.

Progestins

Chronic management of AUB requires episodic or continuous exposure to a progestin. In patients without contraindications, this is best accomplished with an oral contraceptive given the many additional benefits, including decreased dysmenorrhea, decreased blood loss, ovarian cancer prophylaxis, and decreased androgens.

In patients with a pill contraindication, cyclic progestin for 12 days per month using medroxyprogesterone acetate (10 mg/d) or norethindrone acetate (2.5-5 mg/d) provides predictable uterine withdrawal bleeding, but not contraception. Cyclic natural progesterone (200 mg/d) may be used in women susceptible to pregnancy, but may cause more drowsiness and does not decrease blood loss as much as a progestin.

In some women, including those who are unable to tolerate systemic progestins/progesterone or those who have contraindications to estrogen-containing agents, a progestin-secreting IUD may be considered that controls the endometrium via a local release of levonorgestrel, avoiding elevated systemic levels.[10]

Anovulatory bleeding and bleeding disorders

On rare occasions, a young patient with anovulatory bleeding also might have a bleeding disorder. Desmopressin, a synthetic analog of arginine vasopressin, has been used as a last resort to treat abnormal uterine bleeding in patients with documented coagulation disorders. Treatment is followed by a rapid increase in von Willebrand factor and factor VIII, which lasts about 6 hours.

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Surgical Care

Most cases of abnormal uterine bleeding (AUB) can be treated medically. Surgical measures are reserved for situations when medical therapy has failed or is contraindicated.

Dilation and curettage

D&C is an appropriate diagnostic step in a patient who fails to respond to hormonal management. The addition of hysteroscopy will aid in the treatment of endometrial polyps or the performance of directed uterine biopsies. As a rule, apply D&C rarely for therapeutic use in AUB because it has not been shown to be very efficacious.

Hysterectomy

Abdominal or vaginal hysterectomy might be necessary in patients who have failed or declined hormonal therapy, have symptomatic anemia, and who experience a disruption in their quality of life from persistent, unscheduled bleeding.

Endometrial ablation

Endometrial ablation is an alternative for those who wish to avoid hysterectomy or who are not candidates for major surgery.[11] Ablation techniques are varied and can employ laser, rollerball, resectoscope, or thermal destructive modalities. Most of these procedures are associated with high patient satisfaction rates.

Pretreat the patient with an agent, such as leuprolide acetate, medroxyprogesterone acetate, or danazol, to thin the endometrium.

The ablation procedure is more conservative than hysterectomy and has a shorter recovery time. Some patients may have persistent bleeding and require repeat procedures or move on to hysterectomy. Rebleeding following ablation has raised concern about the possibility of an occult endometrial cancer developing within a pocket of active endometrium. Few reported cases exist, but further studies are needed to quantify this risk.

Endometrial ablation is not a form of contraception. Some studies report up to a 5% pregnancy rate in postablation procedures.

A study by Vitagliano et al comparing thermal balloon ablation with transcervical endometrial resection in the treatment of AUB indicated that postoperative pain is greater following the thermal ablation procedure. In the study, 47 women with AUB underwent one of the two procedures, with pelvic pain evaluated one and four hours postoperatively and the need for analgesics assessed. Patients treated with thermal balloon ablation were found to have more pain at both evaluations, and the need for analgesic rescue dose was greater in this group. At 30-day postoperative evaluation, pain seemed to still be greater in these patients. However, complications such as heavy blood loss, uterine perforation, and thermal injuries did not occur in any of the study’s patients.[12]

In a study that compared the efficacy and safety of  the Novasure impedance control system and microwave endometrial ablation (MEA) in 66 women with AUB, women in the former treatment group had significantly higher rates of amenorrhea 1 year following treatment (75.8%) compared with those in the MEA treatment group (24.2%).[13]

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Contributor Information and Disclosures
Author

Millie A Behera, MD Assistant Professor (Adjunct), Division of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, Duke University Medical Center; Medical Director, Bloom Reproductive Institute

Millie A Behera, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, AAGL

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Frances E Casey, MD, MPH Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Society of Family Planning, National Abortion Federation, Physicians for Reproductive Health

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Anthony Charles Sciscione, DO Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for Maternal and Fetal Medicine

Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author John T Queenan, Jr, MD, to the development and writing of this article.

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