Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) Medical Management of Abnormal Uterine Bleeding Notes Handwritten Notes
Control bleeding
Prevent recurrence
Correct anaemia
Improve quality of life
Any interventions should aim to improve quality of life measures.
Management options of AUB
Medical
Surgical
management
management
When should we consider medical management ???
if there is : -
No histological and major structural abnormality
Fibroids <3cm in diameter causing no distortion
of uterine cavity
Medical management is the first line therapeutic option.
Medical treatment options
Non-hormonal treatment
Hormonal treatment
Non-hormonal treatment
Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs)
Commonly used NSAIDs:- mefenamic acid, ibuprofen and
naproxen
reduced menstrual blood loss by 33% to 55%
The effect in reduction of menstrual blood loss is comparable
to COC and progestins.
Less effective than tranexamic acid and LNG-IUS
No individual variations among NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs)
additional benefit of improving dysmenorrhea for up to
70%
Start at the first day of menses and continued for 5 days
or until cessation of menstruation
If it does not improve symptoms within 3 menstrual
cycles, stop treatment.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Adverse effects : nausea, vomiting, abdominal pain,
headache
contraindications : women with bleeding disorders or
platelet function abnormalities
Antifibrinolytic agent (Tranexamic acid)
Synthetic derivative of lysine
Tranexamic acid is an anti-fibrinolytic drug that
reduces blood loss given only with menstruation in
women with heavy menstrual bleeding.
Antifibrinolytic agent (Tranexamic acid)
Antifibrinolytic agent (Tranexamic acid)
Recommonded dose : one gram orally every 6 hours for
the first four days of the cycle
Intravenous tranexamic acid is available for more acute
scenarios, with a dose of 10 mg/kg every 6 hours.
Reduce the menstrual blood loss by up to 40%
does not treat dysmenorrhea
Antifibrinolytic agent (Tranexamic acid)
If tranexamic acid does not decrease menstrual blood loss
within 3 cycles, it should not be continued.
Side effects are usually mild, but may include nausea,
vomiting, diarrhea, and headaches.
The risk of venous thromboembolism by tranexamic acid is
controversial.
Regardless of the lack of evidence, antifibrinolytics should
be used with caution in patients with risk factors for
thrombosis or when prescribed with CHCs.
Antifibrinolytic agent (Tranexamic acid)
Tranexamic acid and NSAIDs can be used together
but should be stopped after 3 months if there is no
symptomatic improvement.
If they are beneficial, they may be continued
indefinitely.
They can also be used as adjuvant therapy with
hormonal preparations.
Hormonal treatment
Combination hormonal contraceptives (CHCs)
Excellent choice for women with abnormal bleeding
who are seeking a reliable method of contraception
progesterone component ? suppress ovulation,
inhibits ovarian steroidogenesis and create endometrial
atrophy
Estrogen component - supports to the endometrium to
reduce unscheduled breakthrough bleeding
Combination hormonal contraceptives (CHCs)
excellent cycle control
significantly reduce menstrual loss (up to 40% to 50%)
improve dysmenorrhea
Combination hormonal contraceptives (CHCs)
Types of CHCs
oral contraceptive pill
contraceptive patch
vaginal ring
All CHCs are effective in reduction
of menstrual blood loss.
Regiemes
21 days, followed by 1 pill free week
reduce MBL up to 40-50%
Continuous use of CHCs without the hormone-free
interval
induce amenorrhea in 80?100% of women by 10?12
months
The possible side effects
Contraindications
breast tenderness
women who are over 35 yrs old
mood change
who smoke
headache
hypertension
nausea
cardiovascular disease
vomiting
migraine with aura
breast cancer
venous thromboembolism or
thrombogenic mutation
Progestins
Safer alternatives for women with fewer contraindications
compared to CHCs
Oral progestin - norethindrone acetate (NETA)
medroxyprogesterone acetate (MPA)
Injectable progestin - medroxyprogesterone acetate
(Depo-Provera)
Progestins
Oral progestin
Long-course (21 days per cycle) reduced
MBL in 63?78% of the women
Short-course luteal phase progestin does
not produce significant benefit.
Possible adverse effects : - unscheduled
bleeding, headache, breast tenderness,
nausea and vomiting
Progestins
Injectable progestin
induces amenorrhea by inhibition of FSH thus inhibiting
follicular development, reducing estradiol synthesis and
secretion resulting in a thin endometrium
Administered every 12 weeks
In trials, over half of the women became amenorrheic after 1
year, but many reported unscheduled bleeding in the first
few months.
excellent contraception
Progestins
Progestin
intrauterine system
(LNG-IUS)
First line of treatment
in AUB (NICE, 2007)
Progestins (LNG-IUS)
Requires an endometrial cavity that is 6 to 9 cm
in length with minimal distortion
Progestins (LNG-IUS)
Approved for heavy menstrual bleeding treatment
for up to 5 years
Minimal concentrations of LNG are absorbed into
the systemic circulation (0.4 to 0.6 nmol/L), limiting
the likelihood of systemic hormonal side effects.
Progestins (LNG-IUS)
amenorrheic by 12 months
Changes in the bleeding pattern
lasting for longer than 6months,
particularly in first few cycles
Should be advised to preserve for
at least 6 cycles to see the
benefits of the treatment
Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing
(Nova T) IUDs during five years of use: a randomized comparative trial.
Contraception 49(1), 56?72 (1994).
Progestins (LNG-IUS)
Drawback:
high cost
spontaneous expulsion (7%)
uterine perforation (1:1000 cases)
Progestins (LNG-IUS)
Common side effects
unscheduled bleeding, breast tenderness, abdominal/pelvic
pain/back pain, headache, ovarian cyst, and acne
Contraindications
pregnancy, unexplained vaginal bleeding,
uterine sepsis
Danazol
Synthetic steroid with androgenic properties
Anti-estrogenic and anti-progestogenic effect
Can reduce the menstrual blood loss up to 80%
Danazol
100 to 400 mg/day in divided doses
20% of women will become amenorrheic and 70%
reported oligomenorrhoea.
The side effects:- androgenic effects such as hot
flushes, myalgia, weight gain and acne, which
occur in 85% of users.
Danazol
significantly more adverse effects than other medical
therapies
should not be used routinely
should be limited to 6 months
GnRH agonists
GnRH agonists
Binds to GnRH receptor
Decreased FSH and LH
GnRH agonists
endometrial atrophy and amenorrhoea within 3?4 weeks
following initiation of treatment
amenorrhea rate of up to 90%
relief from dysmenorrhea associated with adenomyosis and
endometriosis
increase the haematocrit level with minimal side effects
GnRH agonists
reduce uterine and leiomyoma volume by up to 60%
(reverses within months of stopping Rx)
Use as short-term preoperative therapy
adverse effects in long-term: bone pain, loss of bone density,
hot flashes, night sweats and vaginal dryness
Add-back therapy with low-dose estrogen and progestins
(beyond 6 months of treatment)
GnRH agonists
The long-term use of GnRH agonists in abnormal bleeding
should be limited if other medical or surgical treatments are
contraindicated.
the possible temporary "flare" or exacerbation of symptoms
immediately after GnRH injection
Selective progestrone receptor modulators(SPRM)
Selective progestrone receptor modulators (SPRM)
Ulipristal acetate ? the only SPRM to have been
licensed for use in clinical practice
Tissue specific partial progesterone antagonist effect
and
modulates
the
progesterone
receptors
in
endometrium and underlying myometrial tissue resulting
proapoptotic / antiproliferative effects on fibroid cells
Selective progestrone receptor modulators (SPRM)
Control of heavy menstrual bleeding in 90% of women
Amenorrhoea in over 70% of women
Median times to amenorrhea: - 7 days for patients receiving 5
mg of ulipristal acetate
Progestrone receptor modulator associated endometrial
changes (PAEC) - benign, non-physiological, non-proliferative,
histological features of the endometrium
spontaneously reverse over a few weeks to months after
cessation of the 3-month UPA treatment.
Selective progestrone receptor modulators (SPRM)
Median reduction in size of fibroids (12-36%)
After treatment cessation, menstruation usually returns
within 4?5 weeks, but fibroid volume reduction can be
sustained for up to 6 months.
Given as short-term (3 months) pretreatment of fibroid prior
to surgical removal (5-10mg daily)
Selective progestrone receptor modulators (SPRM)
Minor reported side effects ? headache (4%), breast
complaints (4%)
Short-term use of SPRMs resulted in improved quality of
life, reduced menstrual bleeding and high rates of
amenorrhoea.
No publication to date on the clinical utility of SPRMs in the
management of women with heavy menstrual bleeding
without fibroids
Selective estrogen receptor modulators (SERM)
Ormeloxifene is a selective estrogen receptor modulator,
which significantly inhibits endometrial proliferation and
increase haematocrit level among HMB women.
With a dose of 60 mg twice a week
Reduce the menstrual blood loss and endometrial thickness
by 85-97.7%
after 3 months of treatment, 9.5% of the women reporting
amenorrhea
Selective estrogen receptor modulators (SERM)
Side effects :- headache, GI upset, ovarian cyst
Avoid in liver and renal disease, PCOS
Benefit - cost effective, convenient dosage, any age
group, protective to breast and endometrium, use as
contraception
More RCTs required.
Medical treatment options for abnormal uterine
bleeding based on PALM-COEIN etiology
Etiology
Treatment
AUB-P
Multiple polyps or polypoidal endometrium and
(Polyps)
fertility is not desired? LNG-IUS can be
combined with surgical removal
AUB-A
LNG-IUS
(Adenomyosis) If LNG IUS is not accepted? CHCs, NSAIDs,
progestins
GnRH agonists with add back therapy
Medical treatment options for abnormal uterine
bleeding based on PALM-COEIN etiology
Etiology
Treatment
AUB-L
Tranexamic acid or CHCs or NSAIDs, LNG-IUS
(Leiomyoma)
In women >40 years of age, fertility is not desired,
short-term management (up to 6 months)? GnRH
agonists followed by hysterectomy
In women <40 years of age, fertility is desired,
short-term management of GnRH agonists followed
by myomectomy
Long-term GnRH with add-back therapy
Newer medical options: SPRMs
Medical treatment options for abnormal uterine
bleeding based on PALM-COEIN etiology
Etiology
Treatment
AUB-M
Hyperplasia without atypia : -
(Malignancy and LNG-IUS
Endometrial
oral progestins
Hyperplasia)
SPRMs
AUB-C
Tranexamic acid as primary option
(Coagulopathy)
Hormonal treatment with CHCs/LNG-IUS as
secondary option
NSAIDs and injectables were contraindicated.
Medical treatment options for abnormal uterine
bleeding based on PALM-COEIN etiology
Etiology
Treatment
AUB-O
In women desiring contraception; - COC, DMPA,
(Ovulatory
and LNG-IUS
Dysfunction)
In women with cyclic bleeding or predictable in
timing;- NSAIDs and antifibrinolytics
AUB-E
Similar to management of AUB-O
(Endometrial)
Medical treatment options for abnormal uterine
bleeding based on PALM-COEIN etiology
Etiology
Treatment
AUB-I
Medications causing AUB should be changed to
(Iatrogenic
other alternatives
causes)
If no alternatives are available, LNG-IUS is
recommended.
AUB-N
Idiopathic AUB and desire effective contraception:-
(Not defined)
LNG-IUS and CHCs
Cyclic oral progestins (from day 5 to 26), are
recommended if CHCs are contraindicated.
Cyclic bleeding :- NSAIDs and Tranexamic acid
If medical and surgical treatment have failed or
contraindicated:- GnRH with add-back therapy
References
Andersson, K., Odlind, V., Rybo, G. (1994) Levonorgestrel-releasing and
copper-releasing (Nova T) IUDs during five years of use: a randomized
comparative trial. Contraception 49(1), 56?72
Donnez, J., Tatarchuk, T.F. and Bouchard, P. (2012) Ulipristal acetate versus
Leuprolide Acetate for uterine fibroid, N. Engl. J. Med., 366, 421-32
Farrukh,
J.B.,
Towriss,
K.,
McKee,N.
(2015)
Abnormal
uterine
bleeding;Taking the stress out of controlling the flow, Canadian Family
Physician Vol 61
Lethaby, A., Puscasiu, L., Vollenhoven., B (2017) Cochrane Database of
Systematic Reviews; Preoperativemedical therapy before surgery for
uterinefibroids
References
Murji, A., Whitaker, L., Chow, T.L., Sobel, M.L. (2017) Cochrane Database of
Systematic Reviews; Selective progesterone receptormodulators
(SPRMs) for uterine fibroids
Maybin, J.A. and Critchley (2016) Medical management of heavy menstrual
bleeding, Womens health, 12(1), 27-34
NICE (2007) Heavy menstrual bleeding, clinical guidance 44
SOGC (2013) Abnormal uterine bleeding in pre-menopausal women,
Clinical practice guideline No. 292
Sriprasert, I. , Pakrashi, T., Kimble, T. and Archer, D.F. (2017) Heavy
menstrual bleeding diagnosis and medical management, Contraception
and Reproductive Medicine,(2)20
This post was last modified on 11 August 2021