Abnormal Uterine Bleeding – Comprehensive Management Notes

INTRODUCTION & DEFINITIONS

Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity, duration, or schedule in non-pregnant, reproductive-age patients. Consequences can include anemia, reduced quality of life, and can herald endometrial hyperplasia/carcinoma or a systemic bleeding disorder.

FIGO TERMINOLOGY & CLASSIFICATION

• FIGO System 1 → nomenclature/definitions of normal vs abnormal menstruation.
• FIGO System 2 → etiologic classification summarized by acronym PALM-COEIN:
– Polyp
– Adenomyosis
– Leiomyoma
– Malignancy/Hyperplasia
– Coagulopathy
– Ovulatory dysfunction
– Endometrial
– Iatrogenic
– Not otherwise classified
(All structural causes = PALM; non-structural = COEIN.)

NORMAL MENSTRUATION PARAMETERS (FIGO, GRAPHIC)

• Cycle frequency $\ge 24$ and $\le 38$ days
• Duration $\le 8$ days
• Cycle-to-cycle variation $\le 7!\text{–}!9$ days
• Inter-menstrual bleeding: none.

MANAGEMENT GOALS

1. Correct/treat primary etiology when feasible.

2. Improve QoL.

3. Prevent acute hemorrhagic episodes.

4. Prevent/treat anemia & iron deficiency.

5. Establish predictable pattern or achieve amenorrhea.

6. Prevent/treat endometrial hyperplasia/carcinoma.

GENERAL TREATMENT CONSIDERATIONS

• Timing – Immediate therapy if bleeding limits activities or severe anemia; otherwise defer until diagnostics complete.
• Severity – Acute vs non-acute dictates urgency (acute → ED care).
• Associated symptoms – pain, pressure, infertility; screen for bleeding disorders.
• Contraceptive needs/future fertility.
• Comorbidities – e.g., thrombosis risk, hypertension.
• Patient preference, access, cost.
• Proximity to menopause (mean $51.5$ yrs).
• Expectant mgmt reasonable if asymptomatic & non-anemic with close follow-up.

ALGORITHM (“HOW TO CHOOSE”)

1 – KNOWN STRUCTURAL / INFECTIOUS / ENDOCRINE ETIOLOGY

• Polyps → hysteroscopic polypectomy.
• Submucosal fibroids → medical or surgical (hysteroscopic/laparoscopic).
• Adenomyosis → hysterectomy definitive, or LNG-IUD / GnRH analogues.
• Cesarean-scar defect → hysteroscopic, vaginal, laparoscopic, or combined resection (combined approach ↓ bleeding duration).
• AVM → stabilize → uterine artery embolization (UAE) (counsel fertility risk) or laparoscopic bipolar coagulation; hysterectomy if childbearing complete.
• Chronic endometritis → antibiotics.
• Endocrine (hypothyroid, hyperprolactinemia, PCOS) → treat primary disorder; lowers AUB and hyperplasia risk.

2 – NO IDENTIFIED ETIOLOGY

First-line (no contraindication)

• Combined estrogen-progestin contraceptives (COCs, patch, ring).
• $52\,\text{mg}$ levonorgestrel IUD (LNG 52 mg).
– COC reduces menstrual loss $35!–!69\%$; LNG-IUD $71!–!95\%$.
– Selection based on desire for daily pill vs low-maintenance device, near-term fertility, tolerance of initial irregular bleeding.

Reasonable alternatives

• Other progestin therapies: oral norethindrone acetate (NETA) / medroxyprogesterone acetate (MPA); DMPA injection.
• Ultra-low-dose estrogen-progestin (eg ethinyl E2 $5\,\mu g$ + NETA $1\,mg$).
• GnRH analogs, danazol, high-dose estrogen ‑ reserved cases.

SPECIAL POPULATIONS & CONTRAINDICATIONS

Patients at ↑ VTE risk

• Prefer LNG 52 mg; systemic progestin absorption low; no VTE signal in studies of >128{,}000 pts.
• Estrogen-containing therapies generally avoided unless mild thrombophilia without personal/family VTE.
• Oral/injectable progestins show higher VTE ORs: NETA $\text{aOR}\approx3$; MPA $\text{aOR}\approx2$; DMPA data mixed.
• TXA contraindicated; use individualized hematology input.

Other estrogen contraindications

Age $\ge35$ with $\ge15$ cig/day, multiple CVD factors, uncontrolled HTN, ischemic heart disease, stroke, migraine with aura, SLE with APL-Ab, complex valvular dz, etc. LNG 52 mg or progestin-only options favored.

Heavy Menstrual Bleeding (HMB)

Alongside COCs/LNG IUD:
• Tranexamic acid (TXA) $1300\,mg$ TID × $\le5$ days per menses → $26!–!54\%$ loss reduction. Beware active/history thrombosis.
• NSAIDs (ibuprofen $600$ mg q6h, naproxen $500$ mg then $250$–$500$ mg BID, or mefenamic acid $500$ mg TID) → $10!–!52\%$ reduction + dysmenorrhea relief; avoid if on anticoagulant or bleeding disorder.
• Bleeding-disorder specific: EACA, DDAVP, VWF concentrate.

Trying to Conceive

• Short-term COC or cyclic oral progestin (NETA/MPA days $5!–!26$) possible; stop with conception.
• TXA/NSAIDs can be used during menses; unclear ovulation effect.
• Avoid LNG-IUD & DMPA if pregnancy desired within $12!–!24$ mo.

On Anticoagulants

• Up to $\tfrac23$ develop AUB, often dose-dependent (warfarin INR >$3$).
• Evaluate for structural lesions; manage INR $2!–!3$ if feasible.
• Preferred: LNG IUD; combo COC or progestins permissible but discontinue before stopping anticoagulation (procoagulant rebound lasts $\approx6$ wks).

Iron Deficiency

Check ferritin/hemoglobin. Treat AUB and iron deficiency; investigate GI causes if new or age >50 yrs.

DETAILED THERAPIES

Combined Estrogen-Progestin Contraceptives

• Formulations vary by estrogen dose $\le20$–$\ge50\,\mu g$ ethinyl E2, progestin type, route (oral, patch, ring).
• Shorter hormone-free intervals (eg $24$ active / $4$ placebo) ↓ withdrawal bleeding.
• Regimens: cyclic, extended ($84/7$), continuous. Extended may ↑ BTB initially.

LNG 52 mg IUD

• FDA-approved for HMB ×$5$ yrs (contraception $8$ yrs).
• Bleeding ↓ median $93\%$ (3 mo) $98\%$ (6 mo); hemoglobin ↑ $7.5\%$, ferritin ↑ $68.8\%$.
• Expulsion rate up to $20\%$ (adenomyosis $25\%$).
• Replace every $\le5$ yrs for bleeding control (menstrual suppression wanes as intra-uterine levonorgestrel concentration falls).
• Contraindications: distorted cavity, active PID; ultrasound-guided insertion helpful in distorted uteri.

Oral Progestins (NETA & MPA)

• Continuous daily preferred. Starting dose NETA $5$ mg daily; escalate by $5$ mg every $1!–!3$ mo → max $15$ mg. MPA $5!–!30$ mg. Taper once bleeding controlled.
• NETA ≈$10\times$ more endometrial potency than MPA.
• Contraindications mirror thrombosis cautions.

Depot MPA (DMPA)

• $49\%$ menstrual loss reduction at $2$ mo; $50\%$ amenorrheic by $1$ yr.
• Delay to fertility $\ge12$ mo; possible ↑ VTE risk.

Tranexamic Acid

Mechanism: competitive inhibition of plasminogen→plasmin. Dose adjustment if \text{eGFR}<30 mL/min. Adverse: cramps, HA, nausea ≈ placebo.

NSAIDs

Lower endometrial PGE2/PGF2α → vasoconstriction. Start day $1$ bleeding → $2!–!3$ days.

SURGICAL OPTIONS

Endometrial Ablation

• Minimally invasive; appropriate once childbearing complete. LNG IUD vs ablation: similar bleeding reduction/QoL, but LNG group needed >$\times2$ reinterventions at $2$ yrs (RR $2.64$). Pregnancy contraindicated post ablation (but possible) → contraception required.

Hysterectomy

• Definitive; eliminates future uterine/cervical ca + salpingectomy reduces tubo-ovarian ca.
• Randomized $10$-yr data: $46\%$ LNG-IUD pts ultimately had hysterectomy; overall costs lower and urinary incontinence lower in initial IUD group.

WHEN TO REFER

• Heavy/persistent bleeding, suspected malignancy, structural lesions needing surgery, inadequate response to therapy, severe anemia or hemodynamic instability.
• Hematology input: bleeding disorders or complex thrombophilia evaluation.

ETHICAL & PRACTICAL IMPLICATIONS

• Shared decision-making central: contraception, fertility, invasiveness, cultural attitudes, cost/insurance (e.g., NHS discourages routine D&C/hysterectomy for HMB).
• Equity: ensure access to devices (LNG-IUD) and diagnostics regardless of socioeconomic status.

QUICK-REFERENCE STATISTICS & FORMULAS

• Menopause mean age $51.5\;\text{yrs}$ (range wide).
• COC menstrual blood loss ↓ $35!–!69\%$; LNG-IUD ↓ $71!–!95\%$.
• TXA dose $1300\,mg$ TID × $\le5$ days.
• NSAID ibuprofen $600\,mg$ q6h; naproxen loading $500\,mg$ then $250!–!500$ mg BID.
• NETA titration: $5\to15$ mg; taper ↓ $2.5$ mg/month.
• Expulsion risk LNG-IUD up to $20\%$; adenomyosis $25\%$.

RECOMMENDED STUDY FLOW

1. Memorize PALM-COEIN causes + normal menstruation parameters.

2. Master first-line therapies & contraindications.

3. Drill numbers (efficacy %, doses, replacement intervals).

4. Sketch algorithm: etiologic tx → medical → surgical.

5. Review special populations & VTE risk logic.

SUMMARY

Abnormal uterine bleeding management hinges on etiologic correction where possible, otherwise hormonal (COC or LNG-IUD) first-line, modified by thrombosis risk, fertility plans, and comorbidities. TXA/NSAIDs useful for HMB; surgery reserved for refractory or structural cases after childbearing. Ongoing iron therapy and multidisciplinary referral optimize outcomes.

Abnormal uterine bleeding (AUB) is defined as menstrual bleeding of abnormal quantity, duration, or schedule in non-pregnant, reproductive-age patients, potentially leading to anemia, reduced quality of life, and indicating conditions like endometrial hyperplasia/carcinoma or systemic bleeding disorders.

Etiologies are classified by the FIGO PALM-COEIN system: PALM (structural) includes Polyps, Adenomyosis, Leiomyoma, and Malignancy/Hyperplasia; COEIN (non-structural) includes Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified. Normal menstruation parameters are a cycle frequency of $\ge 24$ and $\le 38$ days, duration $\le 8$ days, and cycle-to-cycle variation $\le 7!\text{--}!9$ days.

Management aims to treat the primary etiology, improve quality of life, prevent acute bleeding and anemia, establish predictable patterns, and prevent/treat endometrial hyperplasia/carcinoma. Immediate therapy is needed for severe bleeding or anemia.

For known structural/infectious/endocrine etiologies, specific treatments are applied (e.g., surgical removal for polyps/fibroids, antibiotics for infections, managing underlying endocrine disorders). When no specific etiology is identified, first-line therapies include Combined Estrogen-Progestin Contraceptives (COCs) or the $52\,\text{mg}$ levonorgestrel IUD (LNG 52 mg), both highly effective in reducing menstrual loss. Alternatives include other oral progestins.

Special considerations apply to certain populations:

• Patients at $\uparrow$ VTE risk prefer LNG 52 mg; estrogen-containing therapies are generally avoided.

• For Heavy Menstrual Bleeding (HMB), Tranexamic acid (TXA) and NSAIDs are effective adjuncts to hormonal therapies.

• Those trying to conceive may use short-term COCs, cyclic oral progestins, TXA, or NSAIDs.

• Patients on anticoagulants should be evaluated for structural lesions, with LNG IUD as the preferred option.

• Iron deficiency requires treatment of both AUB and iron deficiency.

Detailed therapies include various COC formulations, the LNG 52 mg IUD (effective for HMB for $5$ years), continuous oral progestins, and DMPA. TXA reduces bleeding by inhibiting plasminogen, while NSAIDs decrease endometrial prostaglandins.

Surgical options include Endometrial Ablation for those with completed childbearing (requires contraception post-procedure) and Hysterectomy as a definitive treatment. Referral is warranted for persistent heavy bleeding, suspected malignancy, structural lesions requiring surgery, or inadequate response to therapy. Shared decision-making is crucial in determining the best approach.