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 [45] [46] :
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Surgery should be considered only in patients in whom medical treatment has failed, cannot be tolerated, or is contraindicated
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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
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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
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Low-dose combination hormonal contraceptive therapy (20-35 μg ethinyl estradiol) is the mainstay of treatment for adolescents up to age 18 years
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Either low-dose combination hormonal contraceptive treatment or progestin therapy is generally effective in women aged 19-39 years; temporary high-dose estrogen therapy may benefit patients with an extremely heavy flow or hemodynamic instability
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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
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If medical therapy fails, patients should undergo further testing (eg, imaging or hysteroscopy)
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An in-office endometrial biopsy is preferable to dilation and curettage (D&C) when initially examining a patient for endometrial hyperplasia or cancer
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If medical therapy fails in a woman in whom childbearing is complete, hysterectomy may be considered
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. [47] 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 an alternate diagnosis if the flow fails to decrease 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. [48]
Levonorgestrel-releasing intrauterine system is considered a first-line treatment for adolescents with heavy menstrual bleeding. [46, 49]
A study by Jain et al indicated that in women with AUB, the NuvaRing, which releases a daily dose of 15 μg ethinyl estradiol and 120 μg etonogestrel, can control heavy menstrual bleeding as effectively as a combined oral contraceptive pill containing 30 μg ethinyl estradiol and 150 μg levonorgestrel. The study included 60 women, who used either the NuvaRing or the combined oral contraceptive pill for 3 consecutive months. Both forms of contraception significantly reduced blood loss in each menstrual cycle, with no significant difference between them on the pictorial blood loss assessment chart. [50]
Estrogen
Intravenous estrogen alone is indicated in emergent clinical situations requiring hospitalization but with a clinically stable patient. Premarin at a dose of 25 mg every 4-6 hours up to 24 hours is recommended. Bleeding typically slows very quickly. If bleeding is not controlled within 12-24 hours, a D&C is indicated.
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.
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. [51]
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 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.
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 and may lead to intrauterine scarring.
Hysterectomy
Abdominal or vaginal hysterectomy might be necessary in patients who have failed or declined hormonal therapy, have symptomatic anemia, are family complete, and 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. [52] 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 post-ablation procedures. This is a significant issue in women who later desire childbearing after an ablation. These pregnancies are very high risk, with essentially an increase in every potential pregnancy complication.
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. [53]
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%). [54]
Endometrial ablation is not an optimal choice in women with adenomyosis or uncorrected submucosal fibroids.
Tables
| Examination | Finding | Differential |
|---|---|---|
| Vital signs | Tachycardia | Anemia Hypovolemia |
| Weight | Obesity | PCOS, weight-related anovulation |
| Eyes | Exophthalmos Periorbital edema |
Graves disease Hypothyroidism |
| Neck | Thyromegaly | Hypothyroidism |
| Breasts | Galactorrhea | Hyperprolactinemia |
| Skin | Increased skin tags Acanthosis nigricans Hirsutism Ecchymosis, purpura |
PCOS Insulin resistance PCOS, CAH, Cushing syndrome, androgen-secreting tumor Bleeding disorder |
| Pelvic examination | Cervical polyp/cervicitis/cervical ectropion Globally enlarged uterus Irregular uterus Adnexal mass |
Adenomyosis Fibroids Ovarian cyst or mass |
| AUB = abnormal uterine bleeding; CAH = congenital adrenal hyperplasia; PCOS = polycystic ovary syndrome. | ||
