Abnormal uterine bleeding

Patients are managed medically with intravenous conjugated oestrogen therapy, or with a combined oral contraceptive, or a progestogen-only hormone-based treatment.[45]American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Apr 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women

Additional treatment recommended for SOME patients in selected patient group

Women will also need correction of anaemia using blood and blood products, and management of specific underlying bleeding disorders.

Tranexamic acid can be used to manage acute AUB.[45]American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Apr 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women [49]American College of Obstetricians and Gynecologists. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Jul 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/07/management-of-abnormal-uterine-bleeding-associated-with-ovulatory-dysfunction

Additional treatment recommended for SOME patients in selected patient group

Women will also need correction of anaemia using blood and blood products, and management of specific underlying bleeding disorders.

Surgical treatment, such as dilation and curettage (D&C), endometrial ablation, uterine artery embolisation, and hysterectomy, may be required. Hysterectomy is only required if profuse persistent uterine bleeding is not responsive to medical oestrogen therapy.[45]American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Apr 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women

In the UK, the National Institute for Health and Care Excellence (NICE) does not recommend D&C as a treatment option for heavy menstrual bleeding.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88

Additional treatment recommended for SOME patients in selected patient group

Women will also need correction of anaemia using blood and blood products, and management of specific underlying bleeding disorders.

Progestogens are first-line treatment for AUB, particularly when associated with anovulation.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [49]American College of Obstetricians and Gynecologists. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Jul 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/07/management-of-abnormal-uterine-bleeding-associated-with-ovulatory-dysfunction

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 heavy menstrual bleeding (HMB) with the levonorgestrel‐releasing intrauterine device.[58]Lethaby A, Hussain M, Rishworth JR, et al. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015 Apr 30;(4):CD002126. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002126.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/25924648?tool=bestpractice.com In the UK, the National Institute for Health and Care Excellence 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 <3cm in size not causing significant uterine cavity distortion.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [Evidence C]a131804e-7b86-4e44-b8eb-386b16bb675bguidelineCWhat are the effects of a levonorgestrel intrauterine device compared with other pharmacological or surgical treatments for abnormal uterine bleeding?​​[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 Other progestogens are recommended if the levonorgestrel intrauterine device is not an option.

Available data do not suggest a benefit from using progestogens during the luteal phase of the menstrual cycle.

Progestogens can be given orally or delivered through progesterone-containing IUDs and contraceptive implants.[60]Shulman LP, Nelson AL, Darney PD. Recent developments in hormone delivery systems. Am J Obstet Gynecol. 2004 Apr;190(4 Suppl):S39-48. http://www.ncbi.nlm.nih.gov/pubmed/15105797?tool=bestpractice.com

Combined oestrogen and progestogen is a second-line therapy that can be used when a progestogen alone is not associated with an adequate response. Combined hormone therapy should not be used in women with contraindications to oestrogen, such as a history of thromboembolic disorders or conditions predisposing for thromboembolism (e.g., smoking, particularly in women >35 years).[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [49]American College of Obstetricians and Gynecologists. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Jul 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/07/management-of-abnormal-uterine-bleeding-associated-with-ovulatory-dysfunction [65]Lethaby A, Wise MR, Weterings MA, et al. Combined hormonal contraceptives for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Feb 11;(2):CD000154. https://www.doi.org/10.1002/14651858.CD000154.pub3 http://www.ncbi.nlm.nih.gov/pubmed/30742315?tool=bestpractice.com

Bleeding usually stops within a few days following the start of therapy. However, increasing the dose may be considered in the absence of a good response (e.g., reduction or cessation of bleeding). This is empirically decided by the physician.

There are no available data based on randomised trials that compare progestogens only versus progestogen and oestrogen combination therapy for AUB.

There are many different combination products and regimens available, including oral formulations and a vaginal ring. See product literature for guidance on dose.

Anti-prostaglandins, such as NSAIDs, have been suggested as a possible useful treatment, particularly when the use of oestrogens and progestogens is contraindicated. They should be taken during menstruation. NSAIDs are contraindicated in peptic ulcer disease and bronchial asthma.

Antifibrinolytic agents, such as tranexamic acid, slow the rate of blood loss and provide symptomatic control during the period itself. [ ] For women with heavy menstrual bleeding, how do antifibrinolytics compare with placebo?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2145/fullShow me the answer [ ] For women with heavy menstrual bleeding, how does tranexamic acid (TXA) compare with progestogens?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2144/fullShow me the answer[Evidence C]e24a7521-c580-4610-992e-d0386c28f1f1ccaCFor women with heavy menstrual bleeding, how does tranexamic acid compare with progestogens?

Usually reserved for cases of significant uterine bleeding not responding to medical treatment. 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]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 ​ D&C with concomitant hysteroscopy may be of value for those patients in whom intrauterine pathology is suspected, or when a tissue sample is desired.[49]American College of Obstetricians and Gynecologists. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Jul 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/07/management-of-abnormal-uterine-bleeding-associated-with-ovulatory-dysfunction [62]Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15;69(8):1915-26. https://www.aafp.org/afp/2004/0415/p1915.html http://www.ncbi.nlm.nih.gov/pubmed/15117012?tool=bestpractice.com

The minimally invasive nature of the procedure and high rate of patient satisfaction have 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]Bofill Rodriguez M, Lethaby A, Fergusson RJ. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2021 Feb 23;2:CD000329. https://www.doi.org/10.1002/14651858.CD000329.pub4 http://www.ncbi.nlm.nih.gov/pubmed/33619722?tool=bestpractice.com

Approaches include hysteroscopic surgical resection with electrocautery and fulguration with roller ball, or the use of alternative energy sources for endometrial destruction, such as laser and cryodestruction.[62]Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15;69(8):1915-26. https://www.aafp.org/afp/2004/0415/p1915.html http://www.ncbi.nlm.nih.gov/pubmed/15117012?tool=bestpractice.com [78]Gupta JK, Sinha A, Lumsden MA, et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2014 Dec 26;(12):CD005073. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005073.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/25541260?tool=bestpractice.com [79]Bofill Rodriguez M, Lethaby A, Grigore M, et al. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Jan 22;(1):CD001501. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001501.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/30667064?tool=bestpractice.com [ ] How do different second‐generation endometrial ablation techniques compare after at least one year in women with heavy menstrual bleeding?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2425/fullShow me the answer [ ] How do first‐ and second‐generation endometrial ablation techniques compare at one year and later in women with heavy menstrual bleeding?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2424/fullShow me the answer [ ] How do ablation techniques compare with transcervical resection of the endometrium at one year and later in women with heavy menstrual bleeding?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2426/fullShow me the answer

Hysteroscopy involves the introduction of a camera into the uterine cavity through a flexible or rigid channel. Operative hysteroscopy allows surgical management of uterine cavity lesions through the hysteroscopic channel.

A definitive and permanent cure; however, open hysterectomy is associated with significant morbidity and, rarely, mortality, particularly in obese women.[75]Chodankar R, Chamberlain J, Rose K. Implications of obesity on gynaecological surgery. Obstet Gynaecol & Reprod Med. 2019 Jul;29(7):195-200​.​ The increasing use of minimally invasive surgery (laparoscopic hysterectomy) has reduced morbidity and promoted more rapid recovery following the procedure.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [49]American College of Obstetricians and Gynecologists. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Jul 2013 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/07/management-of-abnormal-uterine-bleeding-associated-with-ovulatory-dysfunction [62]Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15;69(8):1915-26. https://www.aafp.org/afp/2004/0415/p1915.html http://www.ncbi.nlm.nih.gov/pubmed/15117012?tool=bestpractice.com ​ In obese women, a minimally invasive approach to hysterectomy is preferred to laparotomy.[76]Yong PJ, Thurston J, Singh SS, et al. Guideline no. 386-gynaecologic surgery in the obese patient. J Obstet Gynaecol Can. 2019 Sep;41(9):1356-70.e7. http://www.ncbi.nlm.nih.gov/pubmed/31443850?tool=bestpractice.com ​