Abnormal uterine bleeding

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Exclusion of pregnancy, if appropriate, is the most important initial step in the management of AUB, followed by exclusion of underlying pelvic or systemic disease. The history alone can establish the diagnosis with sufficient confidence in most women with AUB, and treatment can be started without any further laboratory evaluation or imaging. Ovulatory AUB usually presents as heavy menstrual bleeding (HMB) at regular intervals, whereas anovulatory AUB is often characterised by irregular or infrequent bleeding.

The goals of management are to control the current episode of heavy menstrual bleeding, and treat associated complications, most commonly anaemia, and restore a normal menstrual bleeding pattern in subsequent cycles.[45][48] The choice of treatment is guided by the underlying cause of AUB alongside the woman's age, parity, comorbidities, need for uterine and fertility preservation, and personal preference.[3][49][50][51]

Management of acute AUB

Acute AUB may require immediate hospital admission and emergency treatment. This most commonly involves adolescents and women with an underlying bleeding diathesis. The choice of treatment will depend on the clinical stability of the patient, the severity of bleeding, contraindications to medical management, lack of response to medical management, underlying medical conditions, and the need for uterine and fertility preservation.

Patients are managed medically with intravenous conjugated oestrogen therapy, or with a combined oral contraceptive or a progestogen-only hormone-based treatment. Tranexamic acid can be used to manage acute AUB.[45][49]

Intrauterine tamponade with a 26F Foley catheter infused with 30 mL of saline solution has been reported to control bleeding successfully, and may be considered.[52][53]

Surgical treatment, such as endometrial ablation, uterine artery embolisation, hysterectomy, and dilation and curettage (D&C), may be required if profuse and persistent uterine bleeding is not responsive to medical therapy.[45] However, in the UK, the National Institute for Health and Care Excellence (NICE) advises against D&C alone for evaluation or treatment of heavy menstrual bleeding.[3] Women in this group will also need correction of anaemia using blood and blood products. The National Institute for Health and Care Excellence (NICE) does not recommend D&C as a treatment option for HMB.[3]

Management of specific bleeding disorders should be undertaken with a haematologist. Rare causes of bleeding should also be considered (e.g., uterine arteriovenous malformations, which should be managed with an interventional radiologist).[54][55][56]

Management of chronic AUB

Non-pharmacological management

A careful explanation of the cause of the patient's AUB is essential, and exclusion of pathology will often allay fears and provide reassurance, such that women may simply choose to monitor their menstrual cycles using a menstrual calendar. Regular exercise and maintenance of a healthy BMI should be recommended, as high BMI is often associated with ovulatory AUB. Exercise and a healthy diet will also help limit iron deficiency anaemia, raise energy levels, and improve quality of life.[57]

First-line therapy

Progestogens are the first-line treatment for AUB, particularly when associated with anovulation.[3][27][49]
There is no significant difference among various types of progestogens with regard to effectiveness in treating AUB. However, one meta-analysis demonstrated a greater reduction in HMB with the levonorgestrel‐releasing intrauterine device.[58] In the UK, NICE recommends the use of the levonorgestrel intrauterine device as the first-line treatment in women with HMB with no other identified pathology, or with fibroids <3 cm in size not causing significant uterine cavity distortion.[3][Evidence C]
Other progestogens are recommended if the levonorgestrel intrauterine device is not an option.
Anovulation results in continuous unopposed oestrogen stimulation of the endometrium. In cases of chronic anovulation disorders, particularly polycystic ovary syndrome (PCOS), the use of progestogens is helpful for treating AUB as well as preventing the development of endometrial hyperplasia and serious complications, such as endometrial carcinoma.[59]
May be delivered through progestin-containing intrauterine devices and contraceptive implants.[60] Implant users might experience irregular or frequent bleeding. This unpredictable bleeding pattern means it is not a first-line choice in women with AUB.[61]
Cyclic progestins used to manage AUB, such as medroxyprogesterone acetate and norethisterone, are not contraceptive, and so barrier contraception is recommended with their use. Progestins in the form of the progesterone-only pill, the implant (Nexplanon in the UK), and the LNG-IUS have the added benefit of providing contraception.

Second-line therapy:

Combined oestrogen and progestogen is a second-line therapy used when progestogen alone has an inadequate response. It can be used in all patients except in those with contraindications for oestrogen, such as a history of thromboembolic disorders or conditions predisposing for thromboembolism (e.g., smoking, particularly in women >35 years).[3][49][62][63][64][65][66]
Formulations include the monophasic pill (all pills contain the same amount of oestrogen and progestogen) or a triphasic pill (different doses of oestrogen and progestogen formulated to mimic the sequential natural production of oestrogen and progesterone during the menstrual period).
The use of combined oestrogen and progestogen is effective in restoring menstrual bleeding (withdrawal bleeding) in most cases of AUB, whether anovulatory or ovulatory. [ ]
Continuous administration of the combined oral contraceptive pill is licensed for up to 3 consecutive months, with withdrawal bleeding at the end of the 3 months of treatment. This approach is particularly beneficial in those with AUB-associated anaemia.[62]
In the UK, the decision to use contraceptive medications to manage AUB is often made using the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). These evidence-based recommendations offer guidance to providers of contraception regarding who can use contraceptive methods safely. However, they do not indicate a best method nor do they take into account efficacy (and this includes drug interactions or malabsorption). The recommendations consider methods that can be used safely by individuals with certain health conditions (e.g., hypertension) or characteristics (e.g., age) to prevent an unplanned pregnancy. UKMEC is designed to provide information on the use of these synthetic drugs for contraception, rather than as treatment for AUB. The individual risk-benefit analysis of a particular contraceptive method to manage AUB would involve a detailed discussion between the patient and her healthcare provider.[67]

Treatment options when there are contraindications to oestrogen and progestogen therapy:

Because prostaglandins are believed to play a significant role in mediating the pathophysiology of uterine bleeding, anti-prostaglandins, such as non-steroidal anti-inflammatory drugs (NSAIDs), have been suggested as a useful treatment, particularly when the use of oestrogens and progestogens are contraindicated.[68][69] NSAIDs are particularly useful in women with AUB or HMB and associated dysmenorrhoea. They are contraindicated in peptic ulcer disease and bronchial asthma.
Antifibrinolytic agents, such as tranexamic acid, can improve menstrual blood loss by up to 50% per cycle in women with HMB and potentially improve their quality of life. Recent evidence does not suggest that the risk of life-threatening thrombosis is increased with its use, compared with placebo or other HMB treatments.[70] [ ] [Evidence C]

Failure of, or contraindication to, medical treatment; not desiring fertility

Endometrial ablation/resection targets the source of uterine bleeding (the endometrium).[71] The minimally invasive nature of the procedure and a high rate of patient satisfaction has made this procedure an exciting approach, particularly in women with contraindications to hormonal treatment and those with inadequate responses to medical treatment. However, it does not always offer permanent relief, and retreatment may be necessary.[72] Contraception is advised after ablation.[73]

Some studies have compared endometrial ablation with hysterectomy.[74] One Cochrane review suggests that hysterectomy offers permanent and immediate relief from HMB, but is associated with a longer operating time and recovery period. Hysterectomy also has higher rates of postoperative complications. Although the initial cost of endometrial ablation is lower than that of hysterectomy, retreatment is often necessary, and so the cost difference narrows over time.[72]

Another study suggests that laparoscopic assisted supracervical hysterectomy (LASH) is superior to endometrial ablation in terms of clinical effectiveness. Endometrial ablation is less costly in the short term, but expected higher retreatment rates mean that LASH could be considered cost-effective 10 years after the procedure.[74]

Failure of medical treatment and simpler surgical procedures; not desiring fertility

Hysterectomy is a definitive and permanent cure; however, open hysterectomy is associated with significant morbidity and, rarely, mortality, particularly in obese women.[75] The increasing use of minimally invasive surgery (laparoscopic hysterectomy) has reduced morbidity and promoted more rapid recovery following the procedure.[3][49][62] In obese women, a minimally invasive approach to hysterectomy is preferred to laparotomy.[76]

One study comparing hysterectomy with less-invasive options (e.g., endometrial ablation, progestin-containing intrauterine devices, and medication) found some evidence of differences in both efficacy and adverse effects.[77] Hysterectomy was found to be most effective, but with the highest risk of adverse effects. In particular, compared with progestin-containing intrauterine devices, hysterectomy was shown to have superior control of menstrual blood loss.[77]

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