By Rebecca Bowers

EXECUTIVE SUMMARY

Statistics indicate that one-third of outpatient gynecologist visits are for abnormal uterine bleeding, with the condition accounting for more than 70% of gynecologic consultations in the perimenopausal and postmenopausal years.

  • Although medical therapies such as combined oral contraceptives commonly are used to treat the condition, the levonorgestrel-releasing intrauterine device has become an increasingly popular treatment option.
  • Nonsteroidal anti-inflammatory drugs and tranexamic acid also offer oral options for treatment.

Statistics indicate that one-third of outpatient gynecologist visits are for abnormal uterine bleeding, with the condition accounting for more than 70% of gynecologic consultations in the perimenopausal and postmenopausal years.1 Although medical therapies such as combined oral contraceptives commonly are used to treat the condition, the levonorgestrel-releasing intrauterine device (LNG-IUD) has become an increasingly popular treatment option.

Michael Thomas, MD, chief of the division of reproductive endocrinology and infertility at the University of Cincinnati College of Medicine, looks at the LNG-IUD as a safe and effective treatment option, particularly for patients who not only want to control their bleeding, but also want to maintain their fertility potential.

Thomas, a member of the research team responsible for developing the LNG-IUD, served as an advocate for the method during a recent debate at the 2018 American College of Obstetricians and Gynecologists’ (ACOG) annual clinical meeting.2

Birth control pills or other oral options used in controlling abnormal uterine bleeding issues must be taken to be effective, says Thomas, a reproductive endocrinologist. The LNG-IUD remains in place, providing needed therapy, and can be removed when a woman chooses to become pregnant.

Research from seven studies indicates that the LNG-IUD is an effective intervention for reduction of abnormal cyclic uterine bleeding.3 Data suggest 70-87% reductions in bleeding when comparing numbers for treated women with their baseline.4-8 Eighty percent or more of women who were enrolled in studies because they met criteria for heavy menses achieved normal total blood loss, with such improvements showing significant movement when compared with women treated with nonsteroidal anti-inflammatory drugs (NSAIDs), combined oral contraceptives, progestogens, and usual care.3

The LNG-IUD represents a good option for patients with abnormal uterine bleeding who wish to skirt the potential side effects of oral medications, Thomas says.

“People who have issues with progestin-related problems, such as mood changes, nausea, or bloating, may not have that with the IUD, because very little of the medication gets into the peripheral bloodstream,” notes Thomas. “The advantage of this type of local device that is inside the uterus is that it actually has a direct effect, as opposed to taking something by mouth, which has to go through the liver and may not have a good effect.”

Check Other Medical Options

There is no one-size-fits-all approach to the treatment of abnormal uterine bleeding, says Kristen Matteson, MD, MPH, director of the division of research for the department of obstetrics and gynecology at the Warren Alpert Medical School of Brown University and Women & Infants Hospital in Rhode Island. Matteson served as advocate for other medical options at the recent debate.

Heavy menstrual bleeding adversely affects women’s lives, explains Matteson. It may cause them to change their work schedule or change plans with their friends and their family, making a major impact on their day-to-day lives, she notes.

“I think it’s great that we have so many different treatment options, but any treatment that you are looking at giving to a woman with heavy menstrual bleeding needs to address what she is finding most bothersome about her symptom to reduce the adverse impact that bleeding has on her daily life,” she states.

According to a recent survey of ACOG members, combined oral contraceptives were the most commonly chosen first-line choice for abnormal uterine bleeding treatment. Birth control pills can correct menstrual irregularities that result from oligo-ovulation or anovulation, which helps to make menstruation more predictable. Combined oral contraceptives also can decrease excessive menstrual bleeding for most women, which makes them an initial management option in treat heavy menstrual bleeding.

Nonsteroidal anti-inflammatory drugs commonly are used to treat abnormal uterine bleeding because of the role of prostaglandins in the pathogenesis of heavy menstrual bleeding. These drugs inhibit the enzyme cyclooxygenase, thereby lowering endometrial prostaglandin levels and decreasing potential for vasodilation and angiogenesis.3 When compared with placebo, data suggest such drugs decrease menstrual cramping and reduce menstrual blood loss by 33%.10

Tranexamic acid blocks lysine-binding sites on plasminogen, which prevents plasmin and fibrin polymer interaction. This results in degradation of fibrin, stabilization of clots, and reduction in bleeding.11 Research indicates use of the drug results in significant decrease in the objective measurement of idiopathic heavy menstrual bleeding.11

REFERENCES

  1. Committee on Practice Bulletins-Gynecology. Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012;120:197-206.
  2. Thomas MA, Matteson KA. Medication Superheroes Take on the Mighty IUD for Treatment of AUB. Presented at the 2018 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists. Austin, TX; April 2018.
  3. Hartmann KE, Jerome RN, Lindegren ML, et al. Primary Care Management of Abnormal Uterine Bleeding. ARHQ Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality; March 2013.
  4. Najam R, Agarwal D, Tyagi R, et al. Comparison of tranexamic acid with a combination of tranexamic acid and mefenamic acid in reducing menstrual blood loss in ovulatory dysfunctional uterine bleeding (DUB). J Clin Diagn Res 2010;4:3020-3025.
  5. Shaaban MM, Zakherah MS, El-Nashar SA, Sayed GH. Levonorgestrel-releasing intrauterine system compared to low dose combined oral contraceptive pills for idiopathic menorrhagia: A randomized clinical trial. Contraception 2011;83:48-54.
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  7. Reid PC, Virtanen-Kari S. Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: A multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. BJOG 2005;112:1121-1125.
  8. Irvine GA, Campbell-Brown MB, Lumsden MA, et al. Randomised comparative trial of the levonor-gestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia. Br J Obstet Gynaecol 1998;105:592-598.
  9. Matteson KA, Anderson BL, Pinto SB, et al. Practice patterns and attitudes about treating abnormal uterine bleeding: A national survey of obstetricians and gynecologists. Am J Obstet Gynecol 2011;205:321.e1-8.
  10. Lethaby A, Augood C, Duckitt K, et al. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev 2007;(4):CD000400.
  11. Goldstein SR, Lumsden MA. Abnormal uterine bleeding in perimenopause. Climacteric 2017;20:414-420.