Abnormal uterine bleeding: Avoid the rush to hysterectomy

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Applied Evidence

Abnormal uterine bleeding: Avoid the rush to hysterectomy

J Fam Pract. 2009 March;58(3):136-142

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References

1. Nicholson WK, Ellison SA, Grason H, et al. Patterns of ambulatory care use for gynecologic conditions: a national study. Am J Obstet Gynecol. 2001;184:523-530.

2. Wilcox A, Baird DD, Dunson D, et al. Natural limits of pregnancy testing in relation to the expected menstrual period. JAMA. 2001;286:1759-1761.

3. Ely JW, Kennedy CM, Clark EC, et al. Abnormal uterine bleeding: a management algorithm. J Am Board Fam Med. 2006;19:590-602.

4. Dijkhuizen F, Mol B, Brölmann H, et al. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia—a meta-analysis. Cancer. 2000;89:1765-1762.

5. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA. 1993;269:1823-1828.

6. Oehler MK, Rees MC. Menorrhagia: an update. Acta Obstet Gynecol Scand. 2003;82:405-422.

7. Hill DA. Abnormal uterine bleeding. In: Henningsen C, ed. Clinical Guide to Ultrasonography. St. Louis, Mo: Mosby; 2004:173-196.

8. Keshavarz H, Hillis SD, Kieke BA, et al. Hysterectomy surveillance—United States, 1994–1999. MMWR CDC Surveill Summ. 2002;51(SS-5):1-8.

9. Working Party for Guidelines for the Management of Heavy Menstrual Bleeding. An evidence-based guideline for the management of heavy menstrual bleeding. N Z Med J. 1999;112:174-177.

10. Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005;(4):CD002126.-

11. Lähteenmäki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of levonorgestrel releasing intrauterine system as alternative to hysterectomy. BMJ. 1998;316:1122-1126.

12. American College of Obstetricians and Gynecologists (ACOG). Management of anovulatory bleeding. Washington, DC: ACOG; 2000 Mar. 9. ACOG practice bulletin; no. 14.

13. Beaumont H, Augood C, Duckitt K, et al. Danazol for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007;(3):CD001017.-

14. Dawood MY. Nonsteroidal antiinflammatory drugs and reproduction. Am J Obstet Gynecol. 1993;169:1255-1265.

15. Sharp HT. Assessment of new technology in the treatment of idiopathic menorrhagia and uterine leiomyomata. Obstet Gynecol. 2006;108:990-1003.

16. Lethaby A, Shepperd S, Cooke I, et al. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(2):CD000329.-

17. Pron G, Bennett J, Common A, et al. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril. 2003;79:120-127.

First choice: LNG-IUS

The levonorgestrel intrauterine system (LNG-IUS) appears to be the most effective medical therapy for treating menorrhagia, with studies showing a 94% reduction in menstrual blood loss.⁹ The LNG-IUS secretes a small amount of levonorgestrel, which acts locally to keep the endometrium from proliferating. The IUS has not been compared with placebo or no treatment, but it has been found to be more successful than 21-day progestin therapy and somewhat less successful than balloon endometrial ablation.¹⁰

FAST TRACK

Many clinicians use combined oral contraceptives to treat menorrhagia, though data supporting their use are limited.

An interesting study suggested that women given the choice between an LNG-IUS and hysterectomy will choose the intrauterine system rather than undergo invasive surgery. In this study, researchers randomized 56 women waiting to undergo hysterectomy for heavy menstrual bleeding to either continuation of their existing medical treatment or an LNG-IUS. At 6 months, 64% of the women in the IUS group canceled their hysterectomy, whereas only 14% in the medical therapy group did so.¹¹

IUS candidates should have a uterus free of congenital abnormalities that measures between 6 and 9 centimeters by uterine sound, and be at low risk for sexually transmitted infections. Patients who have never been pregnant may use the LNG-IUS. Side effects of the LNGIUS may include irregular menses, amenorrhea, pelvic inflammatory disease, and uterine perforation at insertion.

Hormonal therapy is another option

Various types of hormonal therapy are also effective options for treating abnormal menstrual bleeding.

Combined oral contraceptives (COCs). Although many clinicians use COCs to treat menorrhagia, data supporting this indication are actually limited.¹² COCs are proven to reduce mean menstrual blood loss but have not been well evaluated for patients who complain of heavy menstrual bleeding.⁹

All COCs contain relatively more progestin than estrogen, which benefits patients with abnormal uterine bleeding by thinning the uterine lining, leading to less menstrual blood loss. Newer types of oral contraceptives, such as lower dose pills or extended cycle formulations where patients take 3 months of pills before having a menstrual cycle, have not been studied for treatment of heavy menstrual bleeding.

FAST TRACK

Although NSAIDs are associated with GI bleeding, they actually reduce uterine bleeding.

Progestin alone. There are several formulations of progestins, including intramuscular injections, oral preparations, vaginal suppositories, creams, and the LNG-IUS. Although there are many potential oral progestin regimens—for example, a 10-day course vs a 21-day course—it appears that the 21-day regimen is most effective. Analysis of several trials shows that bleeding was reduced in 86% of women using a 21-day course of oral progestins.⁹

Possible side effects include spotting, weight gain, peripheral edema, and exacerbation of depression. Depot-medroxyprogesterone acetate is an injectable progestin that may cause abnormal bleeding or amenorrhea. It has not been studied as a treatment for heavy menstrual bleeding.

Danazol therapy. Danazol is a synthetic steroid that opposes progesterone and estrogen, leading to endometrial atrophy. Although possibly effective for reducing blood loss, danazol has lost favor due to androgenic side effects such as acne, weight gain, and voice deepening.¹³

NSAIDs reduce bleeding

Although NSAIDs are associated with gastrointestinal bleeding, their effect on uterine bleeding is different. At pharmacologic doses, NSAIDs reduce uterine bleeding. These drugs appear to slow uterine bleeding by helping to constrict the uterine vasculature, reduce prostaglandins, and improve platelet aggregation.¹⁴ Several studies show successful use of NSAIDs for abnormal uterine bleeding. A meta-analysis of NSAID therapy concluded that about half of the menorrhagia patients studied benefitted, and these patients had about a 30% reduction in blood loss.⁹ Mefenamic acid (Ponstel) is the only NSAID currently approved by the US Food and Drug Administration for treating menorrhagia, although all NSAIDs are likely effective.

Consider minimally invasive surgery

The term global endometrial ablation refers to a group of minimally invasive, outpatient procedures designed to destroy the endometrial lining, leading to either reduced bleeding or amenorrhea. These procedures are less invasive than hysterectomy and are best suited for patients with abnormal uterine bleeding who do not have other uterine abnormalities, such as prolapse, dyspareunia, or painful fibroids.

FAST TRACK

Outpatient ablation procedures are relatively fast and allow the patient to return to normal activity quickly.

Examples of global ablation procedures include microwave ablation, cryotherapy, thermal balloon ablation, bipolar radiofrequency ablation, and hydrothermal ablation. Some OB/GYNs perform these procedures in the office.

Ablation procedures have some drawbacks. None of the ablation procedures can guarantee complete amenorrhea. Published amenorrhea rates range from 14% to 55%.¹⁵ Outpatient ablation procedures are relatively fast (usually under 1 hour) and allow the patient to return to normal activity quickly. There is also a cost advantage: endometrial ablation may be 80% less expensive than hysterectomy.