In the treatment of women with abnormal uterine bleeding, once a thorough history,
physical examination, and indicated imaging studies are performed and all significant
structural causes are excluded, medical management is the first-line approach.
Determining the acuity of the bleeding, the patient’s medical history, assessing risk
factors, and establishing a diagnosis will individualize their medical regimen. In acute
abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose
combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic
acid are all viable options, given the appropriate clinical scenario. Heavy
menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system,
combined oral contraceptives, continuous oral progestins, and tranexamic acid with high
efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods
and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone
agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in
preparation for surgical interventions. In women with inherited bleeding disorders all
hormonal methods as well as tranexamic acid can be used to treat abnormal uterine
bleeding. Women on anticoagulation therapy should consider using progestin-only
methods as well as a gonadotropin-releasing hormone agonist to treat their heavy
menstrual bleeding. Given these myriad options for medical treatment of abnormal
uterine bleeding, many patients may avoid surgical intervention.

Medical management recommendations for abnormal uterine bleeding
(choice of therapy depends on the need for contraception and the
contraindications)
Clinical scenarios Medical treatment options
Acute AUBa (normal
uterus without
underlying systemic
cause)
1. IV CEE
2. Oral tranexamic acid
3. Multidose combined monophasic OC
4. Multidose oral progestin
5. GnRH agonist with aromatase inhibitor or antagonist (to prevent

A. Ovulatory AUB
1. LNG-IUS
2. Tranexamic acid
3. Combined OC (cyclic, extended, or continuous)
4. Cyclic or continuous oral progestin (eg, norethisterone),
starting on day 5 for 21 d
5. Injectable progestin (DMPA)
6. NSAIDs
7. GnRH agonist
8. Danazol
B. AUB with ovulatory dysfunction
1. Combined OC
2. MPA (take for 2 wks every 4 wks)
Note: Consider using an NSAID in combination with any of the
previously listed therapies
Symptomatic
leiomyomas
1. LNG-IUS (approved by the FDA in women with an undistorted
uterine cavity size)
2. Combined OCs
3. NSAIDs
4. Danazol
5. Tranexamic acid
Inherited bleeding
disorder
1. Tranexamic acid
2. Combined OC
3. LNG-IUS
4. DMPA
5. Danazol
6. GnRH agonist
7. Desmopressin (vWD)
Anticoagulation
therapy
1. LNG-IUS
2. Oral progestins
3. Depo-Lupron

Focused assessment of abnormal uterine bleeding
History
1. Bleeding pattern
Quantity, frequency of changing pads or tampons, presence of clots, timing during menstrual cycle, impact on quality of life
2. Symptoms of anemia
Headache, palpitations, shortness of breath, dizziness, fatigue, pica
3. Sexual and reproductive history
Use of contraception, sexually transmitted infections, cervical screening, possibility of pregnancy, desire for future pregnancy, known infertility
4. Associated symptoms
Fever, chills, increasing abdominal girth, pelvic pressure or pain, bowel or bladder dysfunction, vaginal discharge or odor
5. Symptoms associated with a systemic cause for AUB
Overweight, obesity, PCOS, hypothyroidism, hyperprolactinemia, hypothalamic or adrenal disorder
6. Chronic medical illness
Inherited bleeding disorders (coagulopathy, blood dyscrasias, platelet functional disorders), systemic lupus erythematosus or other connective
tissue diseases, liver disease, renal disease, cardiovascular disease
7. Medications
Hormonal contraceptives, anticoagulants, SSRIs, antipsychotics, tamoxifen, herbals (eg, ginseng)
8. Family history
Coagulation or thromboembolic disorders, hormone-sensitive cancers
Physical examination
Vital signs: blood pressure, pulse, orthostatics as clinically indicated, weight, BMI
Neck: thyroid examination
Abdomen: tenderness, distension, striae, palpable mass, hepatomegaly
Skin: pallor, bruising, petechia, signs of hirsutism (male hair pattern distribution, acanthotis nigricans) Pelvic examination/inspection: vulva, vagina,
cervix, anus, and urethra
Bimanual examination of uterus and adnexal structures
Rectal examination if bleeding from rectum suspected or risk of concomitant pathology
Testing: Papanicolaou smear, cervical cultures if risk for sexually transmitted infection
Laboratory
Beta hCG
Complete blood count with platelets
Other laboratory testing as clinically indicated
 TSH
 Free testosterone
 Prolactin
 PTT/PT/fibrinogen or thrombin time or von Willebrand diagnostic panel if available at your laboratory
Imaging
TVS or SIS
Office endometrial sampling (as clinically indicated)
Office hysteroscopy (as clinically indicated)