COMMENTARY

How to Manage Abnormal Uterine Bleeding

Peter Kovacs, MD, PhD

Disclosures

March 02, 2016

The Medical Management of Abnormal Uterine Bleeding in Reproductive-Aged Women

Bradley LD, Gueye NA
Am J Obstet Gynecol. 2016;214:31-44

Background

Menstruation occurs at predictable 21- to 35-day intervals and lasts for 3-7 days. A typical blood loss at menstruation is around 30-50 mL. Bleeding that occurs outside of this time frame (metrorrhagia) or menstruation that is much heavier (menorrhagia) is considered abnormal. In a sexually active, reproductive-aged woman, one has to consider the possibility of pregnancy and associated problems first. Once this is ruled out, further workup will determine the cause, and proper treatment can only be recommended based on the test results. This review summarizes the diagnostic and treatment options during the care of the reproductive-aged woman with abnormal uterine bleeding (AUB).

The Study

The authors define AUB as heavy menstruation, intermenstrual bleeding, or the combination of both. It affects up to 14% of reproductive-aged women. It may be related to chronic anovulation or to anatomic defects but could be seen in women with regular ovulation too. In this latter group, AUB is due to a dysregulation of hemostatic and vasoconstrictive mechanisms.

The workup has to start with a detailed history and physical exam during which attention should be paid to signs and symptoms of chronic or acute anemia, as well as to a family history of bleeding disorders. Endocrine abnormalities (thyroid dysfunction, polycystic-ovary syndrome, obesity, hyperprolactinemia, etc.) should be screened for. Anatomic defects can be fairly easily diagnosed using transvaginal ultrasound, particularly with saline infusion sonography. It is important to rule out the possibility of hyperplasia or even cancer among those at higher risk (patients with obesity, long-standing unopposed estrogen exposure, diabetes, or a family history).

Anatomic defects are typically managed surgically. Surgery (hysterectomy or endometrial ablation) may be the alternative for those in whom medical therapies fail and who no longer wish to maintain fertility. Interventional radiologic treatments can also be considered for such women.

There are multiple options for medical treatment. Combined hormonal contraceptive pills have been shown to control the menstrual cycle well and have resulted in significant reduction in blood loss. In more acute cases, high-dose estrogen (oral or intravenous) can be used to stop the bleeding, or high-dose progestin can be given to stabilize the endometrium. The intrauterine progestin-releasing system may also offer a long-term solution as it induces endometrial atrophy and amenorrhea in the majority of users. Androgens (eg, danazol) also induce endometrial atrophy and, therefore, could be effective but are associated with significant side effects.

Gonadotropin-releasing hormone agonists induce a pseudomenopausal state and suspend menstruation and could serve as an alternative when short-term management is considered. Nonsteroidal anti-inflammatory drugs (NSAIDs) influence prostaglandin synthesis and were shown to reduce blood loss by up to 40%.Tranexamic acid prevents fibrin and clot degradation and was found to be effective in the management of AUB.

Patients in whom an inherited bleeding disorder is suspected (most commonly von Willebrand disease) should be seen by a hematologist as well. NSAIDs are contraindicated, but the other medical options can be used for them as well.

AUB is a relatively common complaint among reproductive-aged women. It is associated with reduced quality of life and, if left untreated, may result in medical complications as well. There are numerous effective medical and surgical options to choose from following proper evaluation.

Viewpoint

Excessive menstrual flow or bleeding in between menstruations may be associated with a decreased quality of life and long-term morbidity. Heavy bleeding can lead to anemia, which could lead to more medical problems. Heavy bleeding from the uterus during menstruation may interfere with routine daily activity during those days. Unexpected bleeding could also affect one's sexual life.

There are many options to choose from following a thorough evaluation. These methods should be used to improve quality of life and to avoid long-term medical complications in women with AUB.

Abstract

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