Premenopausal Abnormal Uterine Bleeding

CHARACTERISTICS FEATURES

• Accurate diagnosis of abnormal uterine bleeding (AUB) depends on appropriate categorization and diagnostic tests.
• Pregnancy should always be ruled out as a cause of AUB in reproductive phase women.
• The evaluation of AUB depends on the age and risk factors of the patient.

MANAGEMENT

Treat the underlying cause if any.

For patients with irregular or light bleeding give

• Cap Transamin(Tranexamic acid) 500mg, 2-3 caps PO, TDS for 5 days
• Tab Ponstan forte (Mefenamic acid) 500mg, 1 tab PO TDS for 5 days

Non-hormonal options

• Tab Primolut N (norethisterone acetate) 5mg 1 tab PO OD OR
• Tab Provera (Medroxyprogesterone acetate) 10mg 1 tab PO OD

For 10 days, following which withdrawal bleeding will occur. If successful, the treatment can be repeated for several cycles, starting medication on day 15 of subsequent cycles, or it can be reinstituted if amenorrhea or dysfunctional bleeding reoccurs.

Hormonal options

Women who are experiencing heavier bleeding can be given a taper of any combination of the oral contraceptives (with 30-35 mcg of estrogen estradiol) to control the bleeding. There are several commonly used contraceptive dosing regimens, including four times daily 1 or 2 days followed by 2 pills daily though day 5 and then one pill daily through day 20; after withdrawal bleeding occurs, pills are taken in the usual dosage for three cycles.

For patients with heavier bleeding: In cases of intractable heavy bleeding

Inj Lucrin Depot/Lectrum (Leuprolide) 3.75 mg IM monthly, can be used for up to months to create a temporary cessation of menstruation by ovarian suppression. These therapies require 2-4 weeks to down regulate the pituitary and stop bleeding and will not stop bleeding accurately

In cases of heavy bleeding requiring hospitalization

• Inj Premarin (Conjugated estrogen) 25mg, IV every 4 hourly (3 or 4 doses) then Tab Premarin 1.25mg, 2 tabs PO OD, OR Tab Meliane (Ethinyl estradiol) 20mcg, 1 tab PO OD, for 3 weeks, with the addition of Tab provera 10mg, 1 tab PO OD for 10 days.
• For women with ineffective results from medical management or desiring definitive therapy, surgical options can be considered. Heavy menstrua bleeding due to structural lesions (e.g., fibroids, adenomyosis) is the most common indication for surgery. Minimally invasive procedural options for fibroids include uterine artery embolization and focused ultrasound ablation. Surgical options include myomectomy or hysterectomy.
• For women without structural abnormalities, endometrial ablation has similar results compared to the levonogestrel releasing IUD in reducing menstrual blood loss. Hysteroscopic surgical approaches include endometrial ablation with laser photo-coagulation or electrocautery.
• Nonhysteroscopic techniques include balloon thermal ablation, cryoablation, free fluid thermal ablation, impedance bipolar radiofrequency ablation, and microwave ablation. The latter methods are well adapted to outpatient therapy under local anesthesia.

When to Refer

If bleeding is not controlled with first line therapy.

If expertise is needed for a surgical procedure

When to Admit

If bleeding is uncontrollable wit 1st line therapy or the patient is not hemodynamically stable.