Abnormal Uterine Bleeding in PDF

REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE
Disclaimer: This guideline has been reaffirmed for continued use until further notice Please refer to the Uterine Leiomyoma guide-
line (Guideline no 318, JOGC, February 2015) for specific guidance for fibroid management.
No 292, May 2013 (Replaces No 106, August 2001) (Reaffirmed May 2018)
No. 292-Abnormal Uterine Bleeding in

Pre-Menopausal Women
This clinical practice guideline has been prepared by the

Clinical Practice – Gynaecology Committee, reviewed by the Key Words: Menorrhagia, heavy menstrual bleeding, abnormal
Canadian Paediatric and Adolescent Gynaecology/ Obstetrics uterine bleeding, hysterectomy, hysterectomy, endometrial ablation
Committee, and approved by the Executive and Council of the
Society of Obstetricians and Gynaecologists of Canada.
Sukhbir Singh, MD, Ottawa, ON
Carolyn Best, MD, Toronto, ON Abstract
Sheila Dunn, MD, Toronto, ON Background: Abnormal uterine bleeding is the direct cause of a
Nicholas Leyland, MD, Toronto, ON significant health care burden for women, their families, and
society as a whole. Up to 30% of women will seek medical
Wendy Lynn Wolfman, MD, Toronto, ON
assistance for this problem during their reproductive years. This
guideline replaces previous clinical guidelines on the topic and is
aimed to enable health care providers with the tools to provide the
Clinical Practice – Gynaecology Committee: Nicholas Leyland, latest evidence-based care in the diagnosis and the medical and
MD (Co-chair), North York, ON; Wendy Wolfman, MD (Co-chair), surgical management of this common problem.
Toronto, ON; Catherine Allaire, MD, Vancouver, BC; Alaa
Objective: To provide current evidence-based guidelines for the
Awadalla, MD, Winnipeg, MB; Carolyn Best, MD, Toronto, ON;
diagnosis and management of abnormal uterine bleeding (AUB)
Sheila Dunn, MD, Toronto, ON; Mark Heywood, MD, Vancouver,
among women of reproductive age.
BC; Madeleine Lemyre, MD, Québec City, QC; Violaine Marcoux,
MD, Ville Mont-Royal, QC; Chantal Menard, RN, Ottawa, ON; Outcomes: Outcomes evaluated include the impact of AUB on
Frank Potestio, MD, Thunder Bay, ON; David Rittenberg, MD, quality of life and the results of interventions including medical and
Halifax, NS; Sukhbir Singh, MD, Ottawa, ON. Disclosure surgical management of AUB.
statements have been received from all members of the
committee. Methods: Members of the guideline committee were selected on the
basis of individual expertise to represent a range of practical and
academic experience in terms of location in Canada, type of
practice, subspecialty expertise, and general gynaecology
background. The committee reviewed relevant evidence in the
English medical literature including published guidelines.
Recommendations were established as consensus statements.
J Obstet Gynaecol Can 2018;40(5):e391–e415 The final document was reviewed and approved by the Executive
https://doi.org/10.1016/j.jogc.2018.03.007 and Council of the SOGC.
Copyright © 2018 Published by Elsevier Inc. on behalf of The Society Results: This document provides a summary of up-to-date evidence
of Obstetricians and Gynaecologists of Canada/La Société des regarding diagnosis, investigations, and medical and surgical
obstétriciens et gynécologues du Canada management of AUB. The resulting recommendations may be
This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opin-
ions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written
permission of the publisher.
Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order
to facilitate informed choice women should be provided with information and support that is evidence based, culturally appropriate and tai-
lored to their needs. The values, beliefs and individual needs of each woman and her family should be sought and the final decision about the
care and treatment options chosen by the woman should be respected.
MAY JOGC MAI 2018 • e391

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adapted by individual health care workers when serving women 12 Acute heavy menstrual bleeding may result in significant anemia
with this condition. and emergent care (III).
Conclusions: Abnormal uterine bleeding is a common and 13 Abnormal uterine bleeding in the adolescent most commonly rep-
sometimes debilitating condition in women of reproductive age. resents ovulatory dysfunction related to immaturity of the
Standardization of related terminology, a systematic approach to hypothalamic-pituitary-ovarian axis (II-2).
diagnosis and investigation, and a step-wise approach to Recommendations:
intervention is necessary. Treatment commencing with medical
therapeutic modalities followed by the least invasive surgical 1 Adoption of standardized international terminology for abnormal
modalities achieving results satisfactory to the patient is the uterine bleeding should be considered (III-C).
ultimate goal of all therapeutic interventions. 2 A complete blood count is recommended for women with heavy or
prolonged bleeding (II-2A).
Evidence: Published literature was retrieved through searches of
3 If there is any possibility of pregnancy, a sensitive urine or serum
MEDLINE and the Cochrane Library in March 2011 using
pregnancy test should be performed (III-C).
appropriate controlled vocabulary (e. g., uterine hemorrhage,
4 Testing for coagulation disorders should be considered only in women
menorrhagia) and key words (e. g., menorrhagia, heavy menstrual
who have a history of heavy menstrual bleeding beginning at men-
bleeding, abnormal uterine bleeding). Results were restricted to
arche or who have a personal or family history of abnormal bleeding
systematic reviews, randomized control trials/controlled clinical
(II-2B).
trials, and observational studies written in English and published
5 Thyroid function tests are not indicated unless there are clinical find-
from January 1999 to March 2011. Searches were updated on a
ings suggestive of and index of possible suspicions of thyroid disease
regular basis and incorporated in the guideline to February 2013.
(II-2D).
Grey (unpublished) literature was identified through searching the 6 If imaging is indicated, transvaginal ultrasound should be the first
websites of health technology assessment and health technology- line imaging modality for abnormal uterine bleeding (I-A).
related agencies, clinical practice guideline collections, clinical trial 7 Saline infusion sonohysterography and diagnostic hysteroscopy
registries, and national and international medical specialty should be used in the diagnosis and characterization of discrete in-
societies. trauterine abnormalities such as submucosal fibroids (I-A).
Values: The quality of evidence in this document was rated using the 8 Endometrial biopsy should be considered in bleeding women over
criteria described in the Report of the Canadian Task Force on age 40 or in those with bleeding not responsive to medical therapy,
Preventive Health Care (Table 1). as well as in younger women with risk factors from endometrial cancer
(II-2A).
Benefits, harms, and costs: Implementation of the guideline
9 Office endometrial biopsy should replace dilation and uterine cu-
recommendations will improve the health and well-being of
rettage as the initial assessment of the endometrium for these women
women with abnormal uterine bleeding, their families, and society.
(II-2A).
The economic cost of implementing these guidelines in the
10 Focal lesions of the endometrium that require biopsy should be
Canadian health care system was not considered.
managed through hysteroscopy-guided evaluation (II-2A).
Summary Statements: 11 Non-hormonal options such as non-steroidal anti-inflammatory
1 Abnormal uterine bleeding is a common condition affecting women drugs and antifibrinolytics can be used effectively to treat heavy
of reproductive age that has significant social and economic impact menstrual bleeding that is mainly cyclic or predictable in timing
(II-2). (I-A).
2 Contemporary terminology used to describe abnormal uterine bleed- 12 Combined oral contraceptive pills, depot medroxyprogesterone
ing in reproductive-aged women aims to simplify definitions and to acetate, and levonorgestrel-releasing intrauterine systems signifi-
provide standard descriptions related to patient presentation (III). cantly reduce menstrual bleeding and should be used to treat women
3 The consequences of abnormal uterine bleeding on an individu- with abnormal uterine bleeding who desire effective contraception
al’s overall health determine the degree to which intervention may (I-A).
be required (II-2). 13 Cyclic luteal-phase progestins do not effectively reduce blood loss
4 A thorough history and physical exam will often indicate the cause and therefore should not be used as a specific treatment for heavy
of abnormal uterine bleeding and direct the need for further inves- menstrual bleeding (I-E).
tigation and treatment (III). 14 Danazol and gonadotropin-releasing hormone agonists will effec-
5 Imaging and hysteroscopy offer the clinician additional information tively reduce menstrual bleeding, and may be used for scenarios
to assist in patient assessment and treatment in indicated circum- in which other medical or surgical treatments have failed or are con-
stances (I). traindicated (I-C).
6 Once malignancy and significant pelvic pathology have been ruled 15 Patients receiving a gonadotropin-releasing hormone agonist for
out, medical treatment is an effective first-line therapeutic option for longer than 6 months should be prescribed add-back hormone
abnormal uterine bleeding (I). therapy, if not already initiated with gonadotropin-releasing hormone
7 Medical treatment tailored to the individual woman’s therapeutic goals, agonist commencement (I-A).
desire for contraception, underlying medical conditions, and toler- 16 The progestin intrauterine system has outcomes similar to endo-
ance of side effects will encourage compliance and maximize the metrial ablation for women with heavy menstrual bleeding and thus
likelihood of treatment success (III). may be considered prior to surgical intervention (I-A).
8 Non-hysteroscopic ablation techniques offer similar patient satis- 17 In appropriate candidates, non-hysteroscopic ablation techniques
faction results with fewer risks of complications and less anaesthetic should be the ablation methods of choice in view of their higher ef-
requirement than traditional hysteroscopic ablation (I-A). ficacy and safety than hysteroscopic techniques (I-A).
9 Hysterectomy provides definitive treatment for abnormal uterine 18 With the exception of non-steroidal anti-inflammatory drugs, the same
bleeding. medical agents used to treat heavy menstrual bleeding among women
10 Abnormal uterine bleeding secondary to submucosal fibroids may with normal coagulation can effectively be used in the setting of in-
be managed by hysteroscopic myomectomy. herited bleeding disorders (II-1B).
11 Inherited bleeding disorders may be an underlying cause of abnor- 19 Women with inherited bleeding disorders who have significant heavy
mal uterine bleeding, with von Willebrand’s disease present in the menstrual bleeding or those who fail conventional medical therapy
majority of cases (II-2). are best managed with a multidisciplinary approach (III-C).
e392 • MAY JOGC MAI 2018

No. 292-Abnormal Uterine Bleeding in Pre-Menopausal Women
20 Hysterectomy planning or blood product therapy should be per- 22 High-dose estrogen and tranexamic acid may help decrease or arrest
formed in consultation with a hematologist in patients with inherited acute heavy menstrual bleeding (III-C).
bleeding disorders (III-C). 23 For the adolescent presenting with heavy menstrual bleeding
21 Acute heavy menstrual bleeding should be managed promptly and at or in close approximation to menarche, history and investiga-
systematically to minimize patient morbidity and the need for blood tions should include an assessment for an underlying bleeding
transfusion (III-C). disorder (II-2A).

Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force
on Preventive Health Care
Quality of evidence assessmenta Classification of recommendationsb
I: Evidence obtained from at least one properly randomized A There is good evidence to recommend the clinical preventive
controlled trial action
II-1: Evidence from well-designed controlled trials without B There is fair evidence to recommend the clinical preventive action
randomization C The existing evidence is conflicting and does not allow to make a
II-2: Evidence from well-designed cohort (prospective or recommendation for or against use of the clinical preventive action;
retrospective) or case–control studies, preferably from more than however, other factors may influence decision-making
one centre or research group D There is fair evidence to recommend against the clinical preventive
II-3: Evidence obtained from comparisons between times or places action
with or without the intervention Dramatic results in uncontrolled E There is good evidence to recommend against the clinical
experiments (such as the results of treatment with penicillin in preventive action
the 1940s) could also be included in this category L There is insufficient evidence (in quantity or quality) to make a
III: Opinions of respected authorities, based on clinical experience, recommendation; however, other factors may influence
descriptive studies, or reports of expert committees decision-making
a
The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Pre-
ventive Health Care.
b
Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on
Preventive Health Care.
Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W Canadian Task Force on Preventive Health Care New grades for recommendations from the Canadian
Task Force on Preventive Health Care CMAJ 2003;169:207–8.
INTRODUCTION significantly affect quality of life,3 result in time off work,4

lead to surgical intervention including hysterectomy,5 and
M enstrual disorders are a common indication for medical
visits among women of reproductive age1 and heavy
menstrual bleeding affects up to 30% of women through-
ultimately have a significant impact on the health care system.6
The following guidelines provide a review of the current

out their reproductive lifetime.2 These complaints may diagnosis and management options for abnormal uterine
bleeding among women of reproductive age.
Summary Statement
ABBREVIATIONS
AUB abnormal uterine bleeding 1. Abnormal uterine bleeding is a common condition af-
β-hCG beta-human chorionic gonadotropin
fecting women of reproductive age that has significant
CBC complete blood count
social and economic impact (II-2).
CHC combined hormonal contraceptives
cOCP combined oral contraceptive pill REFERENCES
DMPA depot medroxyprogesterone acetate
FIGO International Federation of Gynecology and Obstetrics 1. Kjerulff K.H., Erickson B.A., Langenberg P.W. Chronic
GnRH gonadotropin releasing hormone
gynecological conditions reported by US women: find-
IUS intrauterine system
ings from the national health interview survey, 1984 to
1992. Am J Public Health 1996;86:195–9.
IV intravenous
2. Market Opinion and Research International (MORI).
LNG levonorgestrel
Women’s health in 1990. [Research study conducted on
LNG-IUS levonorgestrel-releasing intrauterine system HPNCC
hereditary non-polyposis colorectal cancer
behalf of Parke-Davis Laboratories]. London: MORI;
1990.
MPA medroxyprogesterone acetate
3. Barnard K., Frayne S.M., Skinner K.M., Sullivan L.M.
NET norethindrone (or norethisterone)
Health status among women with menstrual symp-
NSAIDs non-steroidal anti-inflammatory drugs
toms. J Womens Health (Larchmt) 2003;12:911–9.
OCP oral contraceptive pill 4. Cote I., Jacobs P., Cumming D. Work loss associated with
PCOS polycystic ovary syndrome increased menstrual loss in the United States. Obstet
SIS saline infusion sonohysterography Gynecol 2002;100:683–7.
VTE venous thromboembolism 5. Millar W. Hysterectomy, 1981/82 to 1996/97. Health Rep
vWF von Willbrand’s factor 2001;12:9–22.

6. Frick K.D., Clark M.A., Steinwachs D.M., et al. Finan- minology related to this topic.2 The suggested nomenclature
cial and quality-of-life burden of dysfunctional uterine for AUB aims to simplify descriptions of this clinical pre-
bleeding among women agreeing to obtain surgical treat- sentation and eliminate terminology such as menorrhagia,
ment. Womens Health Issues 2009;19:70–8. metrorrhagia, and dysfunctional uterine bleeding.
AUB may be defined as any variation from the normal men-

CHAPTER 1: DEFINITIONS
strual cycle, and includes changes in regularity and frequency
Standardized universal terminology is essential in the dis- of menses, in duration of flow, or in amount of blood loss
cussion of AUB to improve communication among Under the category of AUB, further definitions may be sub-
practitioners and to help guide research and education on divided based on volume of menstruation, regularity,
this topic. Review of current terminology in medical and frequency, duration, chronicity, and timing related to repro-
historical literature reveals confusing and inconsistent defi- ductive status Bleeding not related to menses may be further
nitions referring to menstrual bleeding.1 As a result, the FIGO characterized as well Tables 1.1 and 1.2 provides the ter-
Menstrual Disorders Working Group (an international expert minology and descriptions consistent with the FIGO
consensus committee) has developed new guidelines for ter- Menstrual Disorders Working Group consensus statement3,4
Classic descriptions of AUB are based on the cyclicity and

Table 1.1. Terminology for AUB
the quantity of menstrual flow Although the patient’s per-
ception of the bleeding is not necessarily quantifiable, is
Terminology for variations in menstrual bleeding
Volume Regularity Frequency Duration Other
paramount to the management of this problem Ulti-
mately, the woman’s experience and the impact on her quality
Heavy Irregular Frequent Prolonged Intermenstrual
of life determine the degree to which intervention may be
Normal Regular Normal Normal Premenstrual
required The patient’s presentation of AUB depends upon
Light Absent Infrequent Shortened Breakthrough
her subjective experience and impression of the level of
Table 1.2. Definitions of terms for uterine bleeding

Characteristic Terminology Description
Volume Heavy menstrual bleeding Excessive menstrual blood loss which interferes with the woman’s
physical, emotional, social, and material quality of life, and which
can occur alone or in combination with other symptoms.
Regularity (Normal Irregular menstrual bleeding A range of varying lengths of bleeding-free intervals exceeding 20
variation ± 2 to 20 days) days within one 90-day reference period
Absent menstrual bleeding No bleeding in a 90-day period
(amenorrhea)
Frequency (Normal every Infrequent menstrual bleeding Bleeding at intervals > 38 days apart (1 or 2 episodes in a 90-day
24 to 38 days) period)
Frequent menstrual bleeding Bleeding at intervals < 24 days apart (More than 4 episodes in a
90-day period)
Duration (Normal 3 to 8 Prolonged menstrual bleeding Describes menstrual blood loss which exceeds 8 days in duration
days) Shortened menstrual bleeding Menstrual bleeding less than 3 days in duration
Irregular, non-menstrual Intermenstrual Irregular episodes of bleeding, often light and short, occurring
bleeding between otherwise fairly normal menstrual periods
Post-coital Bleeding post-intercourse
Premenstrual and post-menstrual Bleeding that may occur on a regular basis for one or more days
spotting before or after the recognized menstrual period
Bleeding outside Post-menopausal bleeding Bleeding occurring more than one year after the acknowledged
reproductive age menopause
Precocious menstruation Bleeding occurring before the age of 9 years
Acute or chronic AUB Acute AUB An episode of bleeding in a woman of reproductive age, who is not
pregnant, that is of sufficient quantity to require immediate
intervention to prevent further blood loss
Chronic AUB Bleeding that is abnormal in duration, volume, and/or frequency
and has been present for most of the last 6 months

blood loss As a result, a more holistic approach should be gations, and to guide options for management. Determining
taken with these definitions. the amount, frequency, and regularity of bleeding, the pres-
ence of post-coital or intermenstrual bleeding, and any
Heavy menstrual bleeding is the most common com-
dysmenorrhea or premenstrual symptoms can help to dis-
plaint of AUB It has been defined as “excessive menstrual
tinguish anovulatory from ovulatory bleeding or to suggest
blood loss which interferes with the woman’s physical, social,
anatomic causes, such as cervical pathology or endome-
emotional, and/or material quality of life [that] can occur
trial polyps. Ovulatory AUB is usually regular and is often
alone or in combination with other symptoms.”5
associated with premenstrual symptoms and dysmenor-
rhea. Anovulatory bleeding, which is more common near
Summary Statements
menarche and the perimenopause, is often irregular, heavy,
2. Contemporary terminology used to describe abnor- and prolonged. It is more likely to be associated with en-
mal uterine bleeding in reproductive-aged women aims dometrial hyperplasia and cancer.
to simplify definitions and to provide standard de-
scriptions related to patient presentation (III). Further history should include the following:
3. The consequences of abnormal uterine bleeding on
an individual’s overall health determines the degree to • symptoms suggestive of anemia (i.e., light-headedness,
which intervention may be required (II-2). shortness of breath with activity)
• sexual and reproductive history (i.e., contraception, risk
Recommendation for pregnancy and sexually transmitted infections, desire
1. Adoption of standardized international terminology for future pregnancy, infertility, cervical screening)
for abnormal uterine bleeding should be considered • impact on social and sexual functioning and quality of life
(III-C). • symptoms suggestive of systemic causes of bleeding such
as hypothyroidism, hyperprolactinemia, coagulation dis-
REFERENCES orders, polycystic ovary syndrome, adrenal or hypothalamic
disorders, and
1. Woolcock J.G., Critchley H.O., Munro M.G., Broder M.S., • associated symptoms such as vaginal discharge or odour,
Fraser I.S. Review of the confusion in current and his- pelvic pain or pressure
torical terminology and definitions for disturbances of
menstrual bleeding. Fertil Steril 2008;90:2269–80. A family history of inherited coagulation disorders, PCOS,
2. Fraser I.S., Critchley H.O., Munro M.G., Broder M., or endometrial or colon cancer should also be sought, as
Writing Group for this Menstrual Agreement Process. well as any co-morbid conditions, such as hormonally de-
A process designed to lead to international agreement pendent tumours, thromboembolic disease, or cardiovascular
on terminologies and definitions used to describe ab- problems that would influence treatment options. Finally,
normalities of menstrual bleeding. Fertil Steril a list of medications including over-the-counter and natural/
2007;87:466–76. herbal remedies that may interfere with ovulation or
3. Fraser I.S., Critchley H.O., Munro M.G. Abnormal uterine otherwise be associated with bleeding should be obtained
bleeding: getting our terminology straight. Curr Opin (Table 2.1).1–6 Physical assessment (Table 2.2) should look
Obstet Gynecol 2007;19:591–5. for evidence of systemic conditions that can cause abnor-
4. Munro M.G. Abnormal uterine bleeding. Cambridge: mal bleeding and should evaluate the lower genital tract and
Cambridge University Press; 2010. pelvis to confirm the source of bleeding and to look for
5. National Collaborating Centre for Women’s and Chil- anatomic causes such as fibroids or cervical polyps.
dren’s Health, National Institute for Health and Care
A complete blood count is recommended if there is a history
Excellence. NICE guideline CG44: heavy menstrual bleed-
of heavy bleeding.7,8 There is no evidence that routinely mea-
ing. London: Royal College of Obstetricians and
Gynaecologists, 2007. Available at http://www.nice
.org.uk/CG44. Accessed March 28, 2011. Table 2.1. Medications that can be associated with ab-
normal uterine bleeding
CHAPTER 2: EVALUATION
Anticoagulants
Antidepressants (selective serotonin reuptake inhibitors and
History, Physical Examination, And Laboratory tricyclics)1
Investigations Hormonal contraceptives Tamoxifen Antipsychotics (first generation
History and physical examination will help to establish the and risperidone)2,3
Corticosteroids Herbs: ginseng,4 chasteberry,5 danshen6
cause of the abnormal bleeding, to direct further investi-

Table 2.2. Physical assessment classification system for AUB to facilitate greater apprecia-
tion of the complexities of this clinical entity. 10 This
General assessment Gynaecological examination
classification allows the characterization of more than one
Vital signs Inspection: vulva, vagina, cervix,
Weight/BMI anus, and urethra
etiology in the same patient. The PALM side of the clas-
Thyroid exam Bimanual examination of uterus sification refers to structural causes that could be evaluated
Skin exam (pallor, bruising, and adnexal structures and diagnosed on imaging and/or biopsy. The COEIN side
striae, hirsutism, petechiae) Rectal examination if bleeding
allows consideration of underlying medical disturbances that
Abdominal exam (mass, from rectum suspected or risk
hepatosplenomegaly) of concomitant pathology could result in AUB. The full details of this system are avail-
Testing: Pap smear, cervical able through FIGO.10
cultures if risk for sexually
transmitted infection
Summary Statement
4. A thorough history and physical examination will often
suring serum ferritin adds information that will affect indicate the cause of abnormal uterine bleeding and
management if the CBC is normal.9 If there is any chance direct the need for further investigation and treat-
of pregnancy, it should be ruled out through serum β-hCG. ment (III).
Sensitive thyrotropin stimulating hormone levels should be
measured only if there are other symptoms or findings sug- Recommendations
gestive of thyroid disease.7–9 Testing for coagulation disorders 2. A complete blood count is recommended for women
should be considered in women who have a history of heavy with heavy or prolonged bleeding (II-2A).
bleeding starting at menarche, a history of postpartum hem- 3. If there is any possibility of pregnancy, a sensitive urine
orrhage or hemorrhage with dental extraction, evidence of or serum pregnancy test should be performed (III-C).
other bleeding problems, or a family history suggesting a 4. Testing for coagulation disorders should be consid-
coagulation disorder.8 There is no evidence that measure- ered only in women who have a history of heavy
ment of serum gonadotropins, estradiol, or progesterone menstrual bleeding beginning at menarche or who have
levels is helpful in the management of AUB.7 a personal or family history of abnormal bleeding
(II-2B).
The differential diagnosis of AUB can be classified accord- 5. Thyroid function tests are not indicated unless there
ing to the suspected cause, based on findings from the history are clinical findings suggestive of an index of suspi-
and physical examination. Other investigations may then be cions of thyroid disease (II-2D).
undertaken to confirm the cause or to rule out premalig-
nant or malignant disease. Imaging and Pathology
Imaging and hysteroscopy
PALM-COEIN Figo Imaging studies in cases of AUB may be indicated when:
Classification for AUB
There are 9 main categories within the classification system • examination suggests structural causes for bleeding,
named for the acronym PALM-COEIN (Table 2.3) Women • conservative management has failed, or
with what was previously called “dysfunctional uterine bleed- • there is a risk of malignancy
ing” are likely to have one or more of coagulopathy, disorder
of ovulation, or primary endometrial disorder. Ultrasound
An international expert consensus from the FIGO Men- Transvaginal sonography allows detailed assessment of
strual Disorders Working Group has proposed a standardized anatomical abnormalities of the uterus and endometrium.11
In addition, pathologies of the myometrium, cervix, tubes,

and ovaries may be assessed. This investigative modality may
Table 2.3. PALM-COEIN classification of AUB
assist in the diagnosis of endometrial polyps, adenomyo-
Structural causes Non-structural causes
sis, leiomyomas, uterine anomalies, and generalized
Polyps Coagulopathy endometrial thickening associated with hyperplasia and
Adenomyosis Ovulatory dysfunction
Leiomyomas Endometrial (primary disorder of malignancy.
– Submucosal mechanisms regulating local
– Other endometrial “hemostasis”) Saline infusion sonohysterography involves the intro-
Malignancy and hyperplasia Iatrogenic duction of 5 to 15 mL of saline into the uterine cavity during
Not yet specified
transvaginal sonography and improves the diagnosis of

intrauterine pathology. Especially in cases of uterine polyps Endometrial Assessment And Biopsy
and fibroids, SIS allows for greater discrimination of loca- Endometrial assessment in premenopausal women with
tion and relationship to the uterine cavity.12–14 As a result, menorrhagia
SIS can also obviate the need for MRI in the diagnosis and Malignant and premalignant conditions may result in ab-
management of uterine anomalies. normal uterine bleeding and hence pathologic assessment
of the uterine cavity may be required in women at risk.
Clinical Tips
1. Ultrasound endometrial assessment: The endometrium is The evaluation of the endometrium in premenopausal
measured as the maximum anterior-posterior thickness of the
echo on a long-axis transvaginal view of the uterus The normal
women with bleeding can be performed by several modali-
endometrium in a premenopausal woman varies in thickness ties. The endometrium may be assessed directly by
according to the menstrual cycle from 4 mm in the follicular endometrial biopsy, ultrasound, hysteroscopy, or dilation and
phase up to 16 mm in the luteal phase. curettage.
2. SIS is a useful imaging modality prior to planned hystero-
scopic or laparoscopic procedures for fibroids, polyps, and
uterine anomalies to ensure safe and appropriate interventions. Risk factors for premalignant and malignant conditions of
the endometrium
The average age for women with endometrial cancer is 61
MRI years, but 5% to 30% of cases occur in premenopausal
MRI is rarely used to assess the endometrium in patients women.16 Women under the age of 50 share many of the
who have menorrhagia. It may be helpful to map the exact risk factors for endometrial cancer of older women includ-
location of fibroids in planning surgery and prior to thera- ing obesity, diabetes, nulliparity, history of PCOS, and family
peutic embolization for fibroids. It may also be useful in history of hereditary non-polyposis colorectal cancer16–22
assessing the endometrium when transvaginal ultrasound or (Table 2.4).
instrumentation of the uterus (i.e., congenital anomalies)
cannot be performed. Women with HPNCC have a lifetime risk for endometrial
cancer and colorectal cancer of 40% to 60% and a 12% risk
for ovarian cancer. Women who developed 2 primary cancers
Hysteroscopy in their lifetime were identified from 5 large HPNCC reg-
Hysteroscopic evaluation for abnormal uterine bleeding is istries; 51% had endometrial cancer diagnosed first (mean
an option providing direct visualization of cavitary pathol- age 44). Therefore health care providers should be aware
ogy and facilitating directed biopsy.15 that younger women with a diagnosis of endometrial cancer
may be at greater risk of colon and ovarian cancer.23–25
Hysteroscopy may be performed in an office setting with Women with irregular bleeding and a history of nulliparity,
or without minor anaesthesia or in the operating room with obesity, polycystic ovarian syndrome, and diabetes, and a
regional or general anaesthesia. Directed biopsies under direct family history of HPNCC are at greater risk for premeno-
vision provide the main benefit over “blind” dilation and pausal endometrial cancer. Younger women with these risk
uterine curettage. The risks of hysteroscopy include per- factors should be triaged for endometrial assessment.
foration of the uterus, infection, cervical lacerations, creation
of false passages, and fluid overload. Endometrial biopsy
Office endometrial biopsy is a minimally invasive option for
Summary Statement endometrial evaluation in women at risk of malignancy. De-
5. Imaging and hysteroscopy offer the clinician addi- tection rates for malignancy are higher in postmenopausal
tional information to assist in patient assessment and women than in premenopausal women.26
treatment in indicated circumstances (I). Endometrial biopsy can usually be performed easily in a pre-
menopausal woman with a previous vaginal delivery. These
Recommendations
6. If imaging is indicated, transvaginal ultrasound should
be the first line imaging modality for abnormal uterine Table 2.4. Risk factors for endometrial cancer1–7
bleeding (I-A). Age
7. Saline infusion sonohysterography and diagnostic hys- Obesity (BMI > 30 kg/m2)
teroscopy should be used in the diagnosis and Nulliparity
PCOS
characterization of discrete intrauterine abnormali- Diabetes
ties such as submucosal fibroids (I-A). HNPCC

parous women are statistically at very low risk for uterine 2. Thangavelu K., Geetanjali S. Menstrual disturbance and
cancer. There exist many sampling devices with almost galactorrhea in people taking conventional antipsy-
equivalent accuracy. Biopsies are more difficult in women chotic medications. Exp Clin Psychopharmacol
with previous Caesarean sections, who are nulliparous, or 2006;144:459–60.
who have had previous cervical surgeries, such as cone biopsy. 3. Kelly D.L., Conley R.R. Sexuality and schizophrenia: a
The sample detects over 90% of endometrial cancers.27 The review. Schizophr Bull 2004;767–79.
sample is blind and therefore will miss a focal lesion. Hys- 4. Kabalak A.A., Soyal O.B., Urfalioglu A., et al. Meno-
teroscopic directed sampling is recommended in the situation metrorrhagia and tachyarrhythmia after using oral and
of a focal lesion found on ultrasound.15,28 topical ginseng. J Womens Health (Larchmt) 2004;13:
830–3, 1071. [erratum.
Pathology of the endometrium may diagnose endometrial 5. Tesch B.J. Herbs commonly used by women: an
cancer or determine the likelihood of coexistent cancer or evidence-based review. Am J Obstet Gynecol 2003;188(5
a future cancer. For instance, in a recent study, cumulative Suppl):S44–55.
20-year progression of risk among women is less than 5% 6. Wu T., Ni J., Wei J. Danshen (Chinese medicinal herb)
for non-atypical endometrial hyperplasia, but is 28% for atypi- preparations for acute myocardial infarction. Co-
cal endometrial hyperplasia.29 chrane Database Syst Rev 2008;(2):CD004465.
doi:10.1002/14651858.CD004465.pub2.
Clinical Tip
1. Indications for endometrial biopsy in women with abnormal
7. National Collaborating Centre for Women’s and Chil-
uterine bleeding dren’s Health, National Institute for Health and Clinical
• Age > 40 Excellence. Clinical guideline CG44: heavy menstrual
• Risk factors for endometrial cancer (see Table 2.4)
• Failure of medical treatment
bleeding. London: Royal College of Obstetricians and
• Significant intermenstrual bleeding Gynaecologists. Available at http://www.nice.org.uk/
2. Consider endometrial biopsy in women with infrequent menses nicemedia/live/11002/30401/30401.pdf. Accessed
suggestive of anovulatory cycles February 14, 2013.
8. New Zealand National Health Committee Working
Party. Guidelines for the management of heavy men-
Dilatation and curettage strual bleeding. National Health Committee; 1998.
Dilatation and curettage is no longer the standard of care Available at http://www.nzgg.org.nz/guidelines/0032/
for the initial assessment of the endometrium. It is a blind HMB_fulltext.pdf. Accessed February 14, 2013.
procedure, with sampling errors and risks of complica- 9. Krassas G.E., Pontikides N., Kaltsas T., et al. Distur-
tions similar to hysteroscopy.30–32 bances of menstruation in hypothyroidism. Clin
Endocrinol (Oxf) 1999;50:655–9.
Recommendations
10. Munro M.G., Critchley H.O., Broder M.S., et al.
8. Endometrial biopsy should be considered in bleed- FIGO classification system (PALM- COEIN) for
ing women over age 40 or in those with bleeding not causes of abnormal uterine bleeding in nongravid
responsive to medical therapy, as well as in younger women of reproductive age. Int J Gynaecol Obstet
women with risk factors from endometrial cancer 2011;113:3–13.
(II-2A). 11. Vercellini P., Cortesi I., Oldandi S., et al. The role of
9. Office endometrial biopsy should replace dilation and transvaginal ultrasonography and outpatient diagnos-
uterine curettage as the initial assessment of the en- tic hysteroscopy in the evaluation of patients with
dometrium for these women (II-2A). menorrhagia. Hum Reprod 1997;12:1768–71.
10. Focal lesions of the endometrium that require biopsy 12. Wolman I., Jaffa A., Hartoov J., et al. Sensitivity and
should be managed through hysteroscopy- guided specificity of sonohysterography for the evaluation of
evaluation (II-2A). the uterine cavity in perimenopausal patients. J Ultra-
sound Med 1996;15:285–8.
13. Widrich T., Bradley L.D., Mitchenson A.R., et al. Com-
REFERENCES parison of saline infusion sonography with office
hysteroscopy for the evaluation of the endometrium.
1. Damsa C., Bumb A., Bianchi-Demicheli F., et al. Am J Obstet Gynecol 1996;174:1327–34.
“Dopamine-dependent” side effects of selective sero- 14. Farquhar C., Ekeroma A., Furness S., et al. A
tonin reuptake inhibitors: a clinical review. J Clin systematic review of transvaginal ultrasonography,
Psychiatry 2004;65:1064–8. sonohysterography and hysteroscopy for the investigation

of abnormal uterine bleeding in premenopausal women. 29. Lacey J.V. Jr, Sherman M.E., Rush B.B., et al. Abso-
Acta Obstet Gynecol Scand 2003;82:493–504. lute risk of endometrial carcinoma during 20-year follow-
15. van Dongen H., de Kroon C.D., Jacobi C.E., et al. Di- up among women with endometrial hyperplasia. J Clin
agnostic hysteroscopy in abnormal uterine bleeding: a Oncol 2010;28:788–92.
systematic review and meta-analysis. BJOG 2007;114: 30. Grimes D.A. Diagnostic dilation and curettage: a re-
664–75. appraisal. Obstet Gynecol 1982;12:1–5.
16. Soliman P.R., Oh J.C., Schmeler K.M., et al. Risk factors 31. Bettocchi S., Ceci O., Vicino M. Diagnostic approach
for young premenopausal women with endometrial of dilation and curettage. Fertil Steril 2001;75:803–5.
cancer. Obstet Gynecol 2005;105:575–80. 32. Tahir M.M., Bigrigg M.A., Browning J.J., et al. A ran-
17. Farquhar C.M., Lethaby A., Sowter M., et al. An evalu- domized controlled trial comparing transvaginal
ation of risk factors for endometrial hyperplasia in ultrasound, outpatient hysteroscopy and endometrial
premenopausal women with abnormal menstrual bleed- biopsy with inpatient hysteroscopy and curettage. Br J
ing. Am J Obstet Gynecol 1999;181:525–9. Obstet Gynaecol 1999;10:1259–64.
18. Iatrakis G., Zervoudis S., Saviolakis A., et al. Women
younger than 50 years with endometrial cancer. Eur J CHAPTER 3: MEDICAL TREATMENT
Gynaecol Oncol 2006;27:399–400.
19. Schmeler K.M., Soliman P.T., Sun C.C., et al. Endome- Overview
trial cancer in young, normal-weight women. Gynecol Once malignancy and significant pelvic pathology have been
Oncol 2005;99:388–92. ruled out, medical treatment should be considered as the
20. Al-Zoughool M., Dossus L., Kaaks R., et al. Risk of en- first line therapeutic option for abnormal uterine bleeding.
dometrial cancer in relationship to cigarette smoking: Targeted treatment for an underlying medical condition that
results from the EPIC study. Int J Cancer 2007;21: can affect menstrual bleeding, such as hypothyroidism, should
2741–7. be initiated prior to the addition of any of the medical agents
21. Friberg E., Mantzoros C.S., Wolk A. Diabetes and risk described. Women found to be anemic due to uterine bleed-
of endometrial cancer: a population-based prospec- ing should start iron supplementation immediately.
tive cohort study. Cancer Epidemiol Biomarkers Prev
2007;16:276–80. Regular, heavy menstrual bleeding can be successfully treated
22. Pillay O.C., Te Fong L.F., Benjamin E., et al. The as- with both hormonal and non-hormonal options. Non-
sociation between polycystic ovaries and endometrial hormonal treatments such as non-steroidal anti-inflammatory
cancer. Hum Reprod 2006;21:924–9. drugs and antifibrinolytics are taken during menses to reduce
23. Lu K.H., Dinh M., Kohlmann W., et al. Gynecologic blood loss, and thus are effective mainly in the setting of
cancer as a “sentinel cancer” for women with heredi- heavy menstrual bleeding when the timing of bleeding is
tary nonpolyposis colorectal cancer syndrome. Obstet predictable.
Gynecol 2005;105:569–74. Irregular or prolonged bleeding is most effectively treated
24. Lucenteforte E., Talamini R., Montella M., et al. Family with hormonal options that regulate cycles, decreasing the
history of cancer and the risk of endometrial cancer. likelihood of unscheduled and potentially heavy bleeding
Eur J Cancer Prev 2009;8:95–9. episodes. Cyclic progestins, combined hormonal contra-
25. Lancaster J.M., Powell C.B., Kauff N.D., et al. Society ceptives, and the levonorgesterel-releasing intrauterine system
of Gynecologic Oncologists Education Committee state- are examples of effective options in this group, providing
ment on risk assessment for inherited gynaecologic more predictable cycles while protecting the endometrium
cancer predispositions. Gynecol Oncol 2007;107:159–62. from unopposed estrogen and the risk of hyperplasia or car-
26. Dijkhuizen F.P., Mol B.W., Brolmann H.A., et al. The cinoma. Medical therapy can also be useful in some instances
accuracy of endometrial sampling in the diagnosis of to reduce menstrual losses associated with fibroids or
patients with endometrial carcinoma and hyperplasia. adenomyosis.
Cancer 2000;89:1765–72.
27. Stovall T.G., Photopulos G.J., Poston W.M., et al. Pipelle Regardless of the type of abnormal bleeding, a patient-
endometrial sampling in patients with known endome- centred approach to the selection of a specific medical
trial carcinoma. Obstet Gynecol 1991;77:954–6. therapy is essential. Satisfaction and continuation of any given
28. Huang G.S., Gebb J.S., Einstein M.H., et al. Accuracy treatment will be influenced not only by efficacy, but also
of preoperative endometrial sampling for the detec- by the individual woman’s goals and tolerance of side effects.
tion of high-grade endometrial tumors. Am J Obstet The decision to proceed with a trial of medical treatment
Gynecol 2007;196:243, e1-e5. should be based on a discussion of patient preference, desire

Table 3.1. Effective medical treatment options for abnor- Significant differences in efficacy between different NSAIDs
mal uterine bleeding have not been demonstrated, but Naproxen was found to
Non-hormonal Non-steroidal anti-inflammatory drugs
have a higher risk of gastrointestinal side effects than mef-
Antifibrinolytics
enamic acid in one trial.11
Hormonal Combined hormonal contraceptives
Antifibrinolytics
Levonorgestrel-releasing intrauterine system
Plasminogen activators are a group of enzymes that cause
Oral progestins (long phase, days 5 to 26)
fibrinolysis, or the degradation of blood clots. Women with
Depot-medroxyprogesterone acetate
heavy menstrual bleeding have been found to have el-
Danazol
evated endometrial levels of plasminogen activators, with
GnRH-agonists more local fibrinolytic activity than women with normal men-
strual losses.12,13 Tranexamic acid is an antifibrinolytic agent
(or plasminogen activator inhibitor) that reversibly binds to
for fertility or contraception, underlying medical condi- plasminogen to reduce local fibrin degradation without
tions or contraindications, presence of dysmennorrhea, and changing blood coagulation parameters.14
severity of the bleeding. The medical treatment of acute
uterine bleeding will be discussed separately. Table 3.1 sum- Tranexamic acid has been shown to be effective in placebo-
marizes the available medical treatments. The Appendix controlled trials, with an overall reduction in menstrual blood
provides additional details on the mechanisms, dosing regi- loss between 40% and 59% from baseline.15,16 The most com-
mens, efficacy, adverse effects, and contraceptive benefits monly prescribed and studied treatment regimen includes
of each medical treatment option. 1 gram of tranexamic acid taken orally every 6 hours during
menstruation, but a single daily dose of 4 grams has also
Non-Hormonal Treatments been found to be effective.17 Intravenous tranexamic acid
NSAIDS is available for more acute scenarios, with a dose of 10 mg/
Elevated levels of prostaglandin E2 and prostaglandin F2–α kg every 6 hours. Tranexamic acid does not treat
have been demonstrated within the uterine tissues of women dysmenorrhea.
with heavy menstrual bleeding.1 Cyclo-oxygenase converts
arachidonic acid to prostaglandins within the endome- Randomized trials have demonstrated the superiority of
trium NSAIDS reduce total prostaglandin production tranexamic acid to luteal-phase progestins18 and NSAIDS,7
through the inhibition of cyclo-oxygenase,2 shifting the with no significant difference in reported side effects, and
balance between prostaglandins and thromboxanes to a trend towards increased patient-perceived improvement.
promote uterine vasoconstriction.3 Side effects are usually mild, but may include nausea, vom-
iting, diarrhea, and headaches.
In a Cochrane review including 17 randomized trials,
NSAIDs reduced menstrual blood loss by 33% to 55% when Whether the risk of venous thromboembolism is elevated
compared with placebo, without a significant difference in by tranexamic acid is controversial. There were no re-
adverse effects.4 NSAIDs also have the added benefit of im- ported thromboembolic events among the trials investigating
proving dysmenorrhea for up to 70% of patients.5 Although the efficacy of tranexamic acid for “menorrhagia,” but the
mefenamic acid and naproxen are the most extensively studies were underpowered to detect this particular
studied, ibuprofen, diclofenac, indomethacin, and ASA have outcome.16 A small retrospective study examining the use
all been shown be effective when taken during menses. of antifibrinolytics among women at increased risk did not
Therapy ideally begins the day before menses, and contin- indicate an elevated risk of VTE,19 and a population-
ues for 3 to 5 days or until bleeding ceases. Contraindications based study from the United Kingdom showed an incidence
to NSAID therapy include hypersensitivity, pre-existing gas- of VTE with tranexamic acid similar to the spontaneous
tritis, and peptic ulcer disease. Side effects such as frequency of VTE among all women.20 Regardless of the
gastrointestinal upset are unlikely to be significant or cause lack of evidence, many still caution against the use of
discontinuation since therapy continues only for a few days antifibrinolytics among patients with a past history of
each month. thromboembolism.21 A recent case–control study of women
on medical therapy for menorrhagia found a higher risk of
Clinical trials comparing NSAIDs to other medical agents VTE among tranexamic acid users than among users of
have found them to be less effective in objectively reduc- other hormonal and non-hormonal medications, but the dif-
ing menstrual blood loss than tranexamic acid, the combined ference did not reach statistical significance.22 The risk of
oral contraceptive pill, danazol, or the LNG-IUS.6–10 VTE was elevated among all of the women being treated

for menorrhagia in this study, suggesting that “menorrha- Overall and given in any regimen, CHCs represent an ex-
gia” itself may be a pro-thrombotic state. cellent treatment choice for women with abnormal bleeding
who are seeking a reliable method of contraception.
Hormonal Treatments
Combined hormonal contraceptives Oral progestins
CHCs, including the oral contraceptive pill, contraceptive Cyclic progestins, such as medroxyprogesterone acetate or
patch, and vaginal ring, provide excellent cycle control, sig- norethindrone (or norethisterone) taken for 12 to 14 days
nificantly reduce menstrual losses, and improve each month are a recognized treatment for anovulatory bleed-
dysmenorrhea. Menstrual blood loss is reduced up to 40% ing. About 50% of women with irregular cycles will achieve
to 50% in women who take cOCPs in the traditional cyclic menstrual regularity with this regimen,33 with the added
fashion.23,24 The progesterone component provides ovula- benefit of protecting the endometrium from the effects of
tion suppression and inhibits ovarian steroidogenesis to create unopposed estrogen. However, luteal phase progestin alone
endometrial atrophy, while estrogen provides support to the is not an effective treatment for regular heavy menstrual
endometrium to reduce the likelihood of unscheduled break- bleeding. Studies examining the impact of NET 5 mg taken
through bleeding. The majority of the medical orally 2 or 3 times daily for 7 to 11 days a month in women
contraindications to CHCs, including history of thrombo- with regular heavy menses did not demonstrate a signifi-
sis or stroke, uncontrolled hypertension, migraine with cant reduction in mean blood loss from baseline.34 A
neurologic symptoms, coronary artery disease, liver disease, Cochrane meta-analysis including 7 randomized trials con-
and a history of breast cancer, are dangers primarily because cluded that cyclic luteal-phase progestin therapy is
of the estrogen component.25 Please refer to the SOGC clini- significantly less effective in treating “menorrhagia” than
cal practice guideline, “Canadian contraceptive consensus”25 NSAIDS, tranexamic acid, or danazol.35 Common side effects
for further details on contraindications, adverse effects, and from oral progestins include breast tenderness, water re-
troubleshooting tips for CHCs. tention, weight gain, headaches, and acne.
In contrast, long-cycle, high-dose oral progestins have been
Despite the widespread use of cOCPs containing ethinyl
shown to reduce menstrual losses for women with heavy
estradiol for the treatment of heavy menstrual bleeding in
menstrual bleeding. An extended regimen of cyclic oral NET
clinical practice, there remains a paucity of data from ran-
5 mg taken 3 times daily for 21 days (days 5 to 26) was com-
domized trials on their efficacy in this setting.26 A placebo-
pared with the LNG IUS in one trial of 44 women with
controlled randomized trial of a triphasic cOCP among
regular cycles.36 Both groups had a significant reduction in
women with irregular, heavy menses reported that 73 2%
mean blood loss from baseline (87%), but the reduction was
of subjects had a significant improvement in menstrual blood
greater still for those randomized to the LNG-IUS. However,
loss compared with 39 6% in the placebo group.27 The only
the patients taking high-dose oral NET were more likely find
randomized trial of a monophasic pill for ovulatory men-
their treatment unacceptable due to side effects, with 78%
orrhagia included just 45 women, and compared a cOCP
refusing to continue therapy after three months. The like-
with 30 mcg of ethinyl estradiol in a crossover design with
lihood of significant side effects using this high-dose regimen
danazol, tranexamic acid, and naproxen.8 The cOCP reduced
likely limits its practicality.
menstrual losses by 43% from baseline, with a similar im-
provement found among the other treatment groups. The A proportion of women will experience a reduction in men-
contraceptive patch and vaginal ring have not been studied strual blood loss while taking the progesterone-only pill for
specifically for the treatment of abnormal bleeding, but have contraception. This daily (non-cyclic) low-dose regimen of
been found to reduce menstrual losses among normally men- oral NET 0 35 mg has not been studied as a treatment for
struating women,28,29 theoretically making them additional abnormal uterine bleeding.
treatment options.
Injected progestin
Extended-cycle and continuous use of cOCPs, the contra- Depot medroxyprogesterone acetate, while providing ex-
ceptive patch, and the ring reduce both the amount of blood cellent contraception, is often used in clinical practice for
loss per cycle and the number of bleeding episodes per year treating heavy menstrual bleeding.
compared with cOCPs used with a monthly pill-free
period.30–32 This regimen, with prolonged ovarian suppres- DMPA suppresses ovulation and ovarian steroidogenesis,
sion, is particularly helpful for women with dysmenorrhea reducing the estrogen-mediated stimulation of endome-
and pelvic pain, and should be considered in women with trium and ultimately causing endometrial atrophy. In trials
abnormal bleeding who also suffer from these conditions. examining the contraceptive efficacy of DMPA, over half

of the women became amenorrheic after 1 year, but many tomy, LNG-IUS users were compared with women who were
reported unscheduled bleeding in the first few months.37 maintained on a variety of other medical treatments.50 Over
two thirds of the women who had the LNG-IUS inserted
In addition to irregular breakthrough bleeding or spotting, cancelled their surgery versus just 14 3% in the control
other commonly reported side effects include breast ten- group.50
derness, nausea, weight gain, mood disturbance, and a small
reduction in bone mineral density that is reversible upon ces- The most commonly experienced side effects after LNG-
sation. There are no published trials investigating the impact insertion include irregular bleeding and spotting, cramp-
of DMPA on abnormal uterine bleeding. ing, and hormonal side effects such as breast tenderness,
mood changes, and acne. Hormonal symptoms are usually
The levonorgestrel-releasing intrauterine system
mild and dissipate with time, with only 1 to 2 per 100 women
In the absence of significant structural pathology, the LNG- discontinuing therapy at 1 year due to these symptoms.51
IUS has been found to reduce menstrual losses signifi- Irregular bleeding after insertion is common, but typically
cantly, and has recently been approved by Health Canada resolves, and thus patients should be counselled accord-
in the treatment of idiopathic menorrhagia.38,39 It has also ingly. Irregular, prolonged bleeding (more than 8 days) has
been found to improve dysmenorrhea40 and pelvic pain due been reported to decrease from 20% in the first month, to
to endometriosis.41,42 This 32 mm device administers 20 µg just 3% at 3 months.52 Irregular post-insertion bleeding may
of levonorgestrel directly to the endometrium each day, in- take longer to settle among women with menorrhagia, with
ducing endometrial atrophy and reducing mean uterine an average of up to 6 months reported.53
vascular density.42 Minimal concentrations of LNG are ab-
There are a limited number of contraindications to LNG,
sorbed into the systemic circulation (0 4 to 0 6 nmol/L),
but insertion of the LNG-IUS requires an endometrial cavity
limiting the likelihood of systemic hormonal side effects.43
that is 6 to 9 cm in length with minimal distortion. The risk
Both the contraceptive effect and the control of uterine
of expulsion and perforation depends partially on the skill
bleeding have been shown to last up to 5 years.43
of the provider inserting the device. The overall risk of per-
A reduction in menstrual blood loss of 86% at 3 months foration with insertion is less than 1 per 1000.10 The likelihood
and 97% at 12 months was demonstrated in a single- arm of expulsion is 1 in 20 over 5 years, but is most likely to
study on the use of the LNG-IUS in women with menor- occur with the first menses after insertion.54
rhagia, and numerous other studies have reported similar The LNG-IUS should be used with caution among women
results.38,44 Hemoglobin and serum ferritin levels have been who are severely immuno-compromised or at high risk of
shown to increase after insertion of the LNG- IUS among sexually transmitted infections.39 The risk of the develop-
women with anemia due to heavy menstrual bleeding.45,46 ment of pelvic inflammatory disease is greatest within the
Many women will become completely amenorrheic, with re- first 20 days following LNG-IUS placement, and is less than
ported rates in the range of 20% to 80% at 1 year.47 The 1% among low-risk women.55
LNG-IUS has been shown to be substantially superior to
other medical treatments, including NSAIDS and tranexamic Danazol
acid.39 There currently are no published trials comparing the Danazol induces endometrial atrophy by inhibiting ovarian
efficacy of LNG- IUS to combined hormonal contracep- steroidogenesis through suppression of the pituitary- ovarian
tives for abnormal uterine bleeding. axis,56 and has been reported to reduce menstrual losses by
up to 80%.10,57 The typically prescribed regimens range
Several clinical trials have compared the efficacy and ac- between 100 to 400 mg/day in divided doses, with higher
ceptability of the LNG-IUS to surgical treatments for doses generally more effective in controlling bleeding than
abnormal bleeding including ablation and hysterectomy. A lower doses. With lower doses of 100 to 200 mg/day, ap-
Cochrane meta-analysis of 8 trials comparing medical treat- proximately 20% of women will become amenorrheic, and
ment to all surgical methods found that although endometrial the majority will become oligomenorrheic.58 Danazol is as-
destruction, and especially hysterectomy, more effectively sociated with significantly more adverse effects than other
reduce menstrual blood loss, the LNG-IUS provides an medical therapies, specifically including weight gain, acne,
equivalent improvement in quality of life.48 and androgenic effects.
Hurskainen et al randomized women with menorrhagia to Gonadotropin releasing hormone agonists
receive either a hysterectomy or insertion of the LNG- IUS. GnRH agonists induce a reversible hypogonadal state. En-
The two groups had similar health-related quality of life dometrial atrophy and amenorrhea are usually achieved
scores at 5 years.49 In a study of women awaiting hysterec- among premenopausal women within a 3 to 4 week period.59

In addition to effectively treating heavy menstrual bleed- 14. Danazol and gonadotropin-releasing hormone ago-
ing, GnRH agonists provide relief from dysmenorrhea nists will effectively reduce menstrual bleeding, and
associated with adenomyosis and endometriosis.59 Long- term may be used for scenarios in which other medical or
use of GnRH agonists is limited by significant adverse effects, surgical treatments have failed or are contraindi-
including bone pain, loss of bone density, and hypoestrogenic cated (I-C).
effects including hot flashes, night sweats, and vaginal dryness. 15. Patients receiving a gonadotropin-releasing hormone
Add-back therapy with low-dose estrogen and progestins agonist for longer than 6 months should be pre-
will minimize adverse effects, and should be administered scribed add-back hormone therapy, if not already
if therapy is to extend beyond 6 months.60 GnRH ago- initiated with gonadotropin-releasing hormone agonist
nists have been shown to reduce uterine and leiomyoma commencement (I-A).
volume by up to 60%,61 and thus are often used for short-
term preoperative therapy, but the effects are reversed once
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40. Baldaszti E., Wimmer-Puchinger B., Loschke K. Ac- a French clinical study in women aged 35–45 years. Con-
ceptability of the long-term contraceptive levonorgestrel- traception 2002;66:121–8.
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42. Petta C.A., Ferriani R.A., Abrao M.S. Randomized clini- (April 2004). The levonorgestrel-releasing intrauterine
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Pract Res Clin Obstet Gynaecol 2007;21:1007–21. 57. Lamb M.P. Danazol in menorrhagia: a double-blind
44. Andersson J.K., Rybo G. Levonorgestrel-releasing in- placebo controlled trial. J Obstet Gynecol 1987;7:212–6.
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Obstet Gynecol 1990;97:690–4. for heavy menstrual bleeding. Cochrane Database Syst
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and patterns of bleeding after insertion of a 59. Colacurci N., De Placido G., Mollo A. Short term use
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Contraception 1982;6:465–74. uterine bleeding. Clin Exp Obstet Gynecol 1995;22:
46. Xiao B., Wu S.C., Ching J. Therapeutic effects of the 212–9.
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Obstet Gynecol Scand 1999;78:716–21. Leuprolide study group. Obstet Gynecol 1991;77:720–5.
48. Marjoribanks J., Lethaby A., Farquhar C. Surgery versus
medical therapy for heavy menstrual bleeding. Co-
CHAPTER 4: SURGICAL MANAGEMENT
chrane Database Syst Rev 2006;(2):CD003855.
49. Hurskainen R., Teperi J., Rissanen P. Clinical out- Overview
comes and costs with the levonorgestrel-releasing The role of surgery in the treatment of AUB requires a thor-
intrauterine system or hysterectomy for treatment of ough evaluation of the underlying pathology and patient
menorrhagia: randomized trial 5 year follow-up. JAMA factors. The medical treatment of heavy menstrual bleed-
2004;291:1456–63. ing is effective for many women, and treatment with the
50. Lahteenmaki P., Haukkamaa M., Puolakka J. Open LNG-IUS may be comparable to surgical options for im-
randomised study of use of levonorgestrel releasing in- proving quality of life.1
trauterine system as an alternative to hysterectomy. BMJ
1998;316:1122–6. The indications for surgery for women with AUB include
51. American College of Obstetricians and Gynecolo-
gists Committee on Gynecologic Practice. ACOG • failure to respond to medical therapy,
committee opinion. No. 337: noncontraceptive uses of • inability to utilize medical therapies (i.e., side effects,
the levonorgestrel intrauterine system. Obstet Gynecol contraindications),
2006;107:1479–82. • significant anemia,
52. Dubuisson J.B., Mugnier E. Acceptability of the • impact on quality of life, and
levonorgestrel-releasing intrauterine system after dis- • concomitant uterine pathology (large uterine fibroids, en-
continuation of previous contraception: results from dometrial hyperplasia)

Improvement in quality of life is the ultimate goal of treat- Amenorrhea rates varied from 23% to 60%, with 6% to 20%
ment and may occur through achieving eumenorrhea or ultimately requiring a further intervention (usually hyster-
amenorrhea.2 ectomy) in 1 to 5 years of follow-up.
Surgical options for managing AUB depend on several factors Non-hysteroscopic techniques, or “second generation” tech-
including the patient’s expectations and uterine pathology nologies, include a number of varying modalities that all
(Figure). Surgical options include: destroy the endometrium without direct visualization. Devices
currently available in Canada include technologies that use
• dilation and uterine curettage, a heated balloon, a radiofrequency bipolar technology, and
• hysteroscopic polypectomy, a microwave device. These vary in type of energy used, time
• endometrial ablation, required, and outcomes. Comparisons of the varying tech-
• myomectomy, and nologies have been difficult because of the large number
• hysterectomy of competing options available. The main limitation of most
Dilatation and curettage, except possibly in cases of severe non-hysteroscopic devices is their inability to treat uterine
acute bleeding refractory to medical therapy, should be rel- pathologies such as polyps and submucosal fibroids. Large
egated to a diagnostic technique when endometrial sampling or very small uterine cavities may also be contraindicated
or hysteroscopic evaluation is not possible.3,4 in some technologies.
Hysteroscopy Versus Endometrial Ablation Risks of endometrial ablation techniques include uterine per-
Hysteroscopy refers to the direct visualization of the en- foration, infection, hemorrhage, and bowel or bladder injury.
dometrial canal, with the goal of diagnosis or management. Post ablation syndrome is a condition associated with con-
Polypectomy, directed biopsy, and myomectomy may all be comitant or previous tubal ligation and ablation and is a
conducted using this intervention. condition of hematometra resulting in cyclical pain with or
without hematosalpinx. Risks specific to hysteroscopic tech-
Endometrial ablation is a minimally invasive surgical option niques include fluid overload, especially with the use of
for heavy menstrual bleeding. It may be considered in women hypotonic solutions (ex. 1 5% glycine), and resulting hypo-
who have failed medical treatment, have completed child- natremia and its sequelae.6
bearing, or who may not be candidates for major surgery.
Two methods of endometrial ablation may be offered at the Comparisons of hysteroscopic and non-hysteroscopic en-
present time. The first method involves hysteroscopic re- dometrial ablation techniques demonstrate similar patient
section and/or ablation. Previously termed “first generation” satisfaction, with the main difference being risks of the pro-
endometrial ablation, hysteroscopic guided endometrial ab- cedure. Women undergoing non-hysteroscopic procedures
lation has a significant number of years of reported were less likely to have fluid overload, uterine perforation,
experience and effective results. Lethaby et al reported in cervical lacerations, and hematometra than women under-
a meta-analysis of the trials in the Cochrane Database that going hysteroscopic ablation.5 In addition to patient safety,
hysteroscopic ablative methods are highly effective in con- the non-hysteroscopic techniques require less time (average
trolling bleeding in from 87% to 97% of women. 5 15 minutes less) but do have more equipment problems.
Figure. Management of AUB due to fibroids.
Uterine artery
embolization
Hysteroscopy
AUB Fibroids Myomectomy
Laparoscopy/
Laparotomy
Hysterectomy

A number of randomized controlled trials have been per- Hysterectomy

formed comparing endometrial ablative techniques to Hysterectomy offers women with AUB a definitive solu-
hysterectomy.7–11 While an overall patient satisfaction rate tion and is known to have high rates of patient satisfaction.
of > 90% is reported for most types of endometrial abla- However, less invasive options should initially be consid-
tion, up to 30% of women will require hysterectomy within ered in order to avoid the potential complications that
4 years.12 However, hysterectomy is related to more risks for hysterectomy can entail.
the patient and therefore a less invasive option, such as ab-
lation, would offer the patient quicker recovery and a lower If hysterectomy is required, the least invasive method should
risk of complications.13 be offered to women to minimize morbidity and recovery
time. According to a recent Cochrane review,16 the ideal ap-
When compared with the progestin intrauterine system, ab- proach should be in order of least invasive to most. Since
lation appears to have similar efficacy for bleeding control the publication of the last SOGC guidelines17 on hysterec-
in women with menorrhagia and an otherwise normal uterine tomy, the advantages of laparoscopic-assisted hysterectomy
cavity.14,15 when the vaginal approach is not possible have been clari-
fied in several studies, as well as in the Cochrane Review.16
The details of hysterectomy approaches are not within the
Clinical Tips
Key points for counselling women planned for endometrial
scope of this guideline.
ablation:
1. confirm childbearing is complete; Summary Statement
2. require form of contraception;
3. rule out underlying uterine pathology (i.e., hyperplasia or 9. Hysterectomy provides definitive treatment for ab-
malignancy); normal uterine bleeding (I).
4. clearly outline expectations (patient satisfaction, not amenor-
rhea); and
5. discuss the risk of requiring a hysterectomy in the future
Fibroids
Uterine fibroids represent a common structural abnormal-
Summary Statement ity leading to AUB. Abnormal uterine bleeding may result
if a part or entire fibroid is within the uterine cavity. Sub-
8. Non-hysteroscopic ablation techniques offer similar
mucosal fibroids result in heavy and/or irregular bleeding
patient satisfaction results with fewer risks of com-
due to a greater endometrial surface area, unstable vascu-
plication and less anaesthetic requirement than
lature which does not heal and repair as normal endometrium
traditional hysteroscopic ablation (I-A).
would, and inability of the uterus to contract to provide
further compression of endometrial vessels.
Recommendations The management of fibroids may include medical suppres-

16. The progestin intrauterine system has outcomes sion, uterine artery embolization, or surgery. Surgery is
similar to endometrial ablation for women with heavy dependent upon the patient’s desire for future fertility and
menstrual bleeding and thus may be considered prior may include myomectomy or hysterectomy. Myomectomy
to surgical intervention (I-A). may be conducted by laparotomy, laparoscopy, or hyster-
17. In appropriate candidates, non-hysteroscopic abla- oscopy depending on the location and size of the fibroid
tion techniques should be the ablation methods of and on the surgeon’s experience.
choice in view of their higher efficacy and safety than
Further details for the approach to the evaluation and man-
hysteroscopic techniques (I-A).
agement of fibroids are beyond the scope of this guideline.
Clinical Tip Clinical Tips

Several non-hysteroscopic ablation techniques are currently Fibroid localization with imaging is essential for appropriate
available. Balloon, microwave, and radiofrequency ablation management. Saline infusion sonohysterography and
devices have a large reported clinical experience .One of the hysteroscopy provide information on the location of intrauterine
main advantages of these techniques is their successful or submucosal fibroids. These types of fibroids are related to
implementation in a surgical suite or clinic setting, which heavy menstrual bleeding. AUB not responding to medical
avoids the use of operating room resources and general treatment may be due to intracavitary lesions such as
anaesthetic. submucosal fibroids.

Summary Statement 13. Lethaby A., Shepperd S., Cooke I., et al. Endometrial
resection and ablation versus hysterectomy for heavy
10. Abnormal uterine bleeding secondary to submuco- menstrual bleeding. Cochrane Database Syst Rev
sal fibriods may be managed by hysteroscopic 2000;(2):CD000329.
myomectomy (I). 14. Kaunitz A.M., Meredith S., Inki P., et al. Levonorgestrel-
releasing intrauterine system and endometrial ablation
in heavy menstrual bleeding: a systematic review
REFERENCES and meta-analysis. Obstet Gynecol 2009;113:1104–
16.
1. Marjoribanks J., Lethaby A., Farquhar C. Surgery versus 15. Lethaby A.E., Cooke I., Rees M. Progesterone or
medical therapy for heavy menstrual bleeding. Co- progestogen-releasing intrauterine systems for heavy
chrane Database Syst Rev 2006;(2):CD003855. menstrual bleeding. Cochrane Database Syst Rev
2. Abbott J.A., Hawe J., Garry R. Quality of life should 2005;(4):CD002126.
be considered the primary outcome for measuring 16. Nieboer T.E., Johnson N., Lethaby A., et al. Surgical
success of endometrial ablation. J Am Assoc Gynecol approach to hysterectomy for benign gynaecological
Laparosc 2003;10:491–5, discussion 495. disease. Cochrane Database Syst Rev 2009;(3):
3. Grimes D. Diagnostic dilatation and curettage: a reap- CD003677.
praisal. Am J Obstet Gynecol 1982;142:1–6. 17. Lefebvre G., Allaire C., Jeffrey J., et al. Hystérectomie.
4. MacKenzie I., Bibby J. Critical assessment of dilata- Directive clinique de la SOGC n° 109, janvier 2002. J
tion and curettage in 1029 women. Lancet 1978;2: Obstet Gynaecol Can 2002;24:37–61, quiz 74–6.
566–8.
5. Lethaby A., Hickey M., Garry R., et al. Endometrial
resection/ablation techniques for heavy menstrual bleed- CHAPTER 5: SPECIAL SCENARIOS
ing. Cochrane Database Syst Rev 2009;(4):CD001501.
6. Munro M.G. Complications of hysteroscopic and uterine Inherited Bleeding Disorders
resectoscopic surgery. Obstet Gynecol Clin North Am Abnormal uterine bleeding is one of the most common
2010;37:399–425. manifestations of an inherited bleeding disorder, reported
7. Dwyer N., Hutton J., Stirrat G.M. Randomised con- by up to 84% of women with von Willebrand’s disease.1 Con-
trolled trial comparing endometrial resection with versely, 10% to 20% of all women presenting with heavy
abdominal hysterectomy for the surgical treatment of menstrual bleeding will ultimately be found to have an un-
menorrhagia. Br J Obstet Gynaecol 1993;100:237–43. derlying bleeding disorder.2,3 These conditions should
8. Gannon M.J., Holt E.M., Fairbank J., et al. A randomised therefore always be considered on the differential diagno-
trial comparing endometrial resection and abdominal sis for abnormal bleeding Von Willebrand’s disease is the
hysterectomy for the treatment of menorrhagia. BMJ most common inherited disorder, comprising 70% of cases.4
1991;303:1362–4. Less common diagnoses include deficiencies in factor XI,
9. Crosignani P.G., Vercellini P., Apolone G., et al. Endo- VII, or XIII, carrier status for hemophilia A or B, and other
metrial resection versus vaginal hysterectomy for inherited platelet function abnormalities.
menorrhagia: long-term clinical and quality-of-life out-
comes. Am J Obstet Gynecol 1997;177:95–101. Although all women with AUB should have a CBC includ-
10. O’Connor H., Broadbent J.A., Magos A.L., et al. Medical ing platelet count, the need for a further in-depth coagulation
Research Council randomised trial of endometrial re- investigation is determined by a thorough history.5,6 Impor-
section versus hysterectomy in management of tant elements of the history include the pattern and severity
menorrhagia. Lancet 1997;349:897–901. of the bleeding, the past history of bleeding following other
11. Pinion S.B., Parkin D.E., Abramovich D.R., et al. hemostatic challenges, and the family history of bleeding
Randomised trial of hysterectomy, endometrial laser abnormalities or heavy menstrual bleeding. Women with
ablation, and transcervical endometrial resection bleeding disorders may present with a variety of different
for dysfunctional uterine bleeding. BMJ 1994;309: patterns of uterine bleeding at any age, but the majority will
979–83. report heavy, regular, cyclic menses since menarche. Up to
12. Dickersin K., Munro M.G., Clark M., et al. Hysterec- 50% of adolescents presenting with acute bleeding at men-
tomy compared with endometrial ablation for arche will have a coagulopathy,7 and irregular or anovulatory
dysfunctional uterine bleeding: a randomized con- bleeding is almost never caused by a hemostatic abnormal-
trolled trial. Obstet Gynecol 2007;110:1279–89. ity. Once structural uterine abnormalities have been ruled

out, initial investigations should include prothrombin time, menstrual bleeding among women with normal co-
activated partial thromboplastin time, and ferritin when agulation can effectively be used in the setting of
anemia is present. Special testing for von Willbrand’s disease inherited bleeding disorders (II-1B).
(factor VIII level, vWF antigen, and vWF functional assay) 19. Women with inherited bleeding disorders who have
can be ordered by a family physician or gynaecologist, but significant heavy menstrual bleeding or those who fail
interpretation and final diagnoses often require hemato- conventional medical therapy are best managed with
logic consultation. Please refer to the SOGC clinical practice a multidisciplinary approach (III-C).
guideline, “Gynaecological and Obstetric Management of 20. Hysterectomy planning or blood product therapy
Women with Inherited Bleeding Disorders,”6 for a de- should be performed in consultation with a hema-
tailed discussion on the suggested evaluation and testing. tologist in patients with inherited bleeding disorders
(III-C).
Many of the treatments for heavy menstrual bleeding used
among women with normal coagulation can successfully be
Acute Bleeding
used among women with bleeding disorders. The excep-
tion is NSAIDS, which alter platelet function, and thus are Abnormal uterine bleeding may present as an emergent and
contraindicated. The OCP8 and the LNG-IUS9 have both life-threatening condition if blood loss is significant. Sig-
been found to reduce menstrual losses specifically among nificant uterine bleeding may signal a new presentation of
women with inherited bleeding disorders. Injected hor- an underlying systemic problem (i.e., a bleeding disorder),
monal agents such as DMPA and GnRH agonists can be an acute or chronic bleeding problem, or a genital tract ma-
used for women with mild coagulation abnormalities, but lignancy. Management of the symptomatic anemic patient
more prolonged pressure applied to the injection site should with heavy uterine bleeding in the acute setting requires thor-
be performed. Tranexamic acid can effectively used alone ough and timely diagnosis and treatment.
or added to any hormonal treatment method to help control In order to facilitate the acute treatment of patients with
menstrual bleeding among these women.10 profuse abnormal uterine bleeding the following steps should
be considered:
When the typical hormonal and non-hormonal methods of
treating uterine bleeding have failed, specific treatment in-
cluding desmopressin or factor replacement can be Stabilizing the patient
considered. These treatments should only be administered General principles of acute resuscitation should be fol-
with the assistance of a hematologist. Desmopressin, which lowed in all emergent cases. Assessment of vital signs (blood
releases vWF from platelets, has been used to treat bleed- pressure, heart rate, cognition) will help triage patients who
ing in mild coagulation disorders.11 It can be given during are actively bleeding. In patients with signs of hypovole-
menstruation intravenously, intranasally, or subcutane- mia due to bleeding, immediate intravenous fluid resuscitation
ously. Conservative surgical treatment for refractory cases, should be started using crystalloid solution and blood prod-
including the various methods of endometrial destruc- ucts as necessary.
tion, can safely and effectively be performed in the setting
of bleeding disorders.12 Hysterectomy, if needed, should be Examination/diagnosis
planned carefully along with a hematologist, for measures Upon presentation a diagnosis is required to help direct
to normalize coagulation factors preoperatively, intraopera- therapy Pregnancy must be ruled out upon presentation using
tively, and postoperatively are needed in order to avoid history and chemical testing Once pregnancy has been ex-
excessive blood loss. cluded, an examination will delineate the source of bleeding
(see examination section) The volume of blood loss may
Summary Statement be estimated by examining the patient for hemodynamic
11. Inherited bleeding disorders may be an underlying changes and hypovolemia.
cause of abnormal uterine bleeding, with von
Willebrand’s disease present in the majority of cases • Although diagnosis is required, biopsy should be ar-
(II-2). ranged in a timely fashion. If uterine bleeding is the cause,
a biopsy may be performed but does not change man-
Recommendations agement in an acute setting and may not provide an
18. With the exception of non-steroidal anti-inflammatory accurate result if bleeding is significant.
drugs, the same medical agents used to treat heavy • Ultrasound will help determine whether fibroids, ovarian
pathology, or other causes of bleeding are present.

• Bloodwork to assess for anemia, and in cases of signifi- Surgery in the acute situation should remain a last resort due
cant blood loss, workup for disseminated intravascular to the morbidity associated with operating on patients with
coagulation, should be considered. acute anemia and the resulting impaired healing, further
bleeding, and infection. Surgical options in the acute setting
include uterine curettage and hysteroscopic ablation,15 hys-
Management of acute uterine bleeding
terectomy, and uterine artery embolization.
Once a patient with acute uterine bleeding has been
resuscitated with IV fluids and blood products, as neces- Summary Statement
sary, the source of bleeding must be managed. Medical
management is the preferred first line treatment and 12. Acute heavy menstrual bleeding may result in sig-
surgery should be reserved for cases unable to be managed nificant anemia and emergent care (III).
medically. Medical management of acute uterine bleeding
Recommendations
includes:
21. Acute heavy menstrual bleeding should be managed
• IV estrogen is available as conjugated estrogens 25 mg promptly and systematically to minimize patient mor-
every 6 hours13,14 bidity and the need for blood transfusion (III-C).
• Oral estrogen and/or OCP provided in high doses of 22. High-dose estrogen and tranexamic acid may help de-
cOCP, is the simplest form of treatment, and often will crease or arrest acute heavy menstrual bleeding (III-C).
include a total of 100 mcg of ethinyl estradiol. Sug-
gested regimens include two 35 mcg estrogen OCP tablets The Adolescent
per day for 5 days, then reduced to once a day. This may AUB is common in the adolescent population, and heavy
be started with the IV therapy above. menstrual bleeding is experienced by 12 1% to 37% of
• Nausea is a common side effect of high-dose estrogen adolescents.16–18 Symptoms from AUB at puberty may be
and so should be mitigated by anti-nausea medications sufficient to cause interference with school performance.
as needed.14 Adolescents’ relative inexperience with menstruation may
• Tranexamic acid may also be started at a dose of 1000 mg also lead to concern as to whether their symptoms are normal
q6h IV or per os. or not. A menstrual diary or pictorial blood assessment chart
• Alternatives to the above regimens include high-dose pro- score can be helpful in this situation. The health care pro-
gestins such as MPA (10 to 20 mg twice daily) or megestrol vider can assist the young woman and her family to
acetate (20 to 60 mg twice daily). understand what are normal versus abnormal menstrual
cycles.
Maintenance treatment The etiology of AUB in adolescents has a similar differen-

Once an acute episode has resolved, patients may be given tial diagnosis to that of adult women, however the relative
daily OCP or tranexamic acid treatment until they are re- proportion of causes differs. Within the PALM-COEIN
evaluated by endometrial biopsy or ultrasound. GnRH Classification of AUB, the structural causes (leiomyomas,
agonists may provide further suppression of the endome- adenomyosis) are rare in adolescents.19,20
trium to offer patients symptomatic relief and time to correct
anemia until a final treatment decision can be made. GnRH AUB in adolescents is most often related to an immature
agonists when given alone may cause an exacerbation of hypothalamic-pituitary-ovarian axis. Within the first year fol-
uterine bleeding after the first dose. This may be avoided lowing menarche up to 85% of cycles may be anovulatory.
by maintaining patients on some type of suppressive therapy The proportion of ovulatory cycles increases with time from
such as the OCP for the first week to 10 days. menarche but by the fourth gynaecologic year just over half
(56%) are ovulatory.21 Thus for an adolescent presenting
within the first few years of menarche, after an appropri-
Unable to treat medically or failure of medical treatment ate directed history and focused investigations, ovarian
Medical treatment with high-dose estrogen or anti- dysfunction is often the etiology.
fibrinolytics may be contraindicated in patients at high risk
of thrombosis. This includes women with active VTE, in- The age at presentation is important when considering eti-
herited thrombophilias, myocardial infarction, cerebrovascular ologies beyond an immature hypothalamic-pituitary- ovarian
accidents, and diagnosed malignancy. If there is a clear con- axis. Oligomenorrhea at the age of 15 is most predictive of
traindication or if medical treatment fails, a surgical approach persistent cycle irregularity by early adulthood and war-
may be required. rants more widespread assessment.22 Adolescents presenting

with heavy menstrual bleeding at or close to menarche, par- considered first line therapies in sexually active adoles-
ticularly those who require visits to the emergency cents, as well as in non-sexually active adolescents with
department, admission, or blood transfusion, may have a individualized counselling. Past concerns regarding use of
bleeding disorder in up to 48% of cases.19,23–26 the progestin IUS for adolescents have included nulliparity,
with smaller uteri and risks of expulsion, and pelvic inflam-
Other important diagnostic considerations are related to matory disease. Attitudes and guidelines have moved towards
sexual activity. Confidential history taking should explore considering progestin IUS as a first line option in this younger
whether the adolescent is sexually active to rule out preg- population.27–29 Multiple studies have shown their safety and
nancy related causes, contraceptive side effects, and sexually efficacy, although their use in adolescents under 16 years of
transmitted infections as an etiology for AUB. age has been limited.30,31 The progestin IUS has also been
used in adolescents with bleeding disorders, with drastic im-
Evaluation provements in both pictorial bleeding assessment chart and
For a sexually active adolescent the physical examination does quality of life scores.32
not differ from that applied to an adult woman. However Danazol and GnRH agonists are not typically suggested
for the non-sexually active adolescent, assessment would gen- for adolescents due to their side effect profiles.33 Surgical
erally not include a speculum or bimanual examination, but therapy including hysteroscopy, endometrial ablation, and
would rely on external assessment of the genitalia and ab- hysterectomy generally have no role in the management of
dominal examination. Ultrasound may therefore be helpful AUB in adolescents. Surgery is limited to the rare struc-
to rule out the rare structural cause of AUB in adolescents, tural anomaly (e.g., polyp or fibroid) that requires directed
but is again limited to the transabdominal approach based therapy.
on sexual activity. Transvaginal ultrasound, saline infused
sonohysterography, hysteroscopy, and MRI rarely play a role Summary Statement
in the adolescent investigation.
13. Abnormal uterine bleeding in the adolescent most
The initial laboratory assessment in this age group does commonly represents ovulatory dysfunction related
not differ from that recommended for adult women: an to immaturity of the hypothalamic-pituitary-ovarian
initial CBC, thyroid-stimulating hormone if there are axis (II-2).
symptoms of thyroid disease, and a β-hCG to exclude
pregnancy. Further testing is directed by history, symp-
toms, and physical examination. As previously explained, Clinical Tips
investigations for a bleeding disorder should be per- 1. Selection of a medical therapy for AUB in adolescents should
consider the need for contraception. Long acting reversible con-
formed if heavy menstrual bleeding onset is at or shortly traception may be considered first line therapy for both sexually
following menarche. active adolescents and, with individualized counselling, non-
sexually active adolescents.
2. Oligomenorrhea at age 15 is highly predictive of persistent oli-
Treatment gomenorrhea in early adulthood and warrants investigation.
Therapy in adolescents, as in adult women, should be chosen
based on the underlying etiology, the acuity of the presen-
tation, and the side effect profile. All medical options, both Recommendation
non-hormonal and hormonal, can be applied to adoles-
cents. An important consideration is the need for 23. For the adolescent presenting with heavy menstrual
contraception CHCs are an effective first line option for ado- bleeding at or in close approximation to menarche,
lescent patients. Long-acting reversible contraceptives history and investigations should include an assess-
(injectable progestin, progestin IUS) may be also be ment for an underlying bleeding disorder (II-2A).

APPENDIX
Summary Table Of Medical Treatments For Abnormal Uterine Bleeding
Treatment Dose/Regimen Mechanism Contraindications Adverse effects Efficacy/Benefits Contraception

Hormonal
CHC (Combined 1 Daily pill (cOCP) for 21 days Suppression pituitary- History VTE or stroke, Breast tenderness, mood Menstrual regularity, 20% Yes
hormonal each month, ovarian axis, uncontrolled HTN, change, fluid retention, to 50% reduction in
contraceptives) 2 Continuous or extended endometrial atrophy smoking > 15/day, over 35 BTB MBL, reduction in
regimen, years, migraine with aura, Rare: VTE, stroke MI dysmenorrhea and PMS
3 Contraceptive ring or patch breast cancer, CAD, active
cyclic or continuous renal/liver disease
LNG-IUS 20 µg per 24 hours local LNG, Local suppression Large intracavitary pathology, Irregular bleeding first 6 70% to 97% reduction in Yes
one IUS for up to 5 years endometrial breast cancer, recurrent/ months, breast MBL, amenorrhea in up
proliferation and recent PID tenderness, acne, to 80% at 1 year,
vascularity cramping, headaches reduced dysmenorrhea
Cyclic oral MPA 5 to 10 mg po for 10 to Inhibits endometrial Pregnancy, breast cancer, Breast tenderness, mood Bleeding reduced by up to No (But will reduce
progesterone 14 d (luteal, anovulatory), proliferation liver disease, changes, bloating, acne, 87% with long phase ability to conceive
NET 5 mg tid day 5–26 headaches, weight gain regimen while on tx)
(long phase, ovulatory)
Injected DMPA 150 mg IM q90 days Inhibits ovarian Pregnancy, breast cancer, Irregular bleeding, breast 60% amenorrhea at 12 Yes
progesterone steroidogenesis and active liver disease, liver tenderness, weight gain, months, 68% at 24
endometrial tumours mood changes, months
proliferation decreased BMD

(reversible)
Danazol 100 to 400 mg po daily Inhibits ovarian Liver disease Weight gain, acne, muscle 80% reduction MBL, 20% No
steroidogenesis, cramps, GI upset, amenorrhea, 70%
endometrial atrophy irritability oligomenorrhea
GnRH agonists Leuprolide acetate (Lupron) Stops ovarian Allergy, suspected pregnancy Hypoestrogenic symptoms Bleeding stopped in 89% No
IM monthly, 3 to 6 months steroisogenesis, (hot flashes, night by 3 to 4 weeks
(add back recommended if endometrial atrophy sweats, vaginal
over 6 months) dryness), bone pain,
loss of BMD, mood
changes
Non-hormonal
NSAIDS Naprosyn 500 mg od-bid, Reduction in Allergy, renal disease, Indigestion, worsening/ 20% to 50% reduction No
ibuprofen 600 to 1200 mg endometrial untreated hypertension, exacerbation of asthma, MBL, reduction in
od, Mefenamic acid 500 mg prostaglandins platelet or coagulation gastritis or peptic ulcers dysmenorrhea in 70%
od starting day 1 or day disorders, active gastritis or
before menses for 3 to 5 peptic ulcers
days or until ceases
Antifibrinolytics Tranexamic acid Reversible blockade Past history VTE Indigestion, diarrhea, 40% to 59% reduction in No
(Cyclokapron) 1 gram po plasminogen, inhibits headaches, leg cramps MBL
qid, 4 grams po daily single fibrinolysis
dose, during menses
HTN: hypertension; CAD: coronary artery disease; BTB: breakthrough bleeding; MI: myocardial infarction; MBL: menstrual blood loss; PMS: premenstrual syndrome; PID: pelvic inflammatory disease; BMD: bone
mineral density; GI: gastrointestinal; IM: intramuscular.
REFERENCES 14. DeVore G.R., Owens O., Kase N. Use of intravenous

Premarin in the treatment of dysfunctional uterine
1. Kirtava A., Crudder S., Dilley A., et al. Trends in the bleeding–a double-blind randomized control study.
clinical management of women with vonWillebrand Obstet Gynecol 1982;59:285–91.
disease: a survey of 75 women enrolled in haemophilia 15. Franchini M., Cianferoni L. Emergency endometrial re-
treatment centres in the United States. Haemophilia section in women with acute, severe uterine bleeding.
2004;10:158–61. J Am Assoc Gynecol Laparosc 2000;7:347–50.
2. Kadir R.A., Economides D.L., Lee C.A., et al. Fre- 16. Barr F., Brabin L., Agbaje S., et al. Reducing iron de-
quency of inherited bleeding disorders in women with ficiency anaemia due to heavy menstrual blood loss in
menorrhagia. Lancet 1998;351:485–9. Nigerian rural adolescents. Public Health Nutr
3. Edlund M., Blomback M., von Schoultz B., et al. On 1998;1:249–57.
the value of menorrhagia as a predictor for coagula- 17. Friberg B., Orno A.K., Lindgren A., et al. Bleeding dis-
tion disorders. Am J Hematol 1996;53:234–8. orders among young women: a population-based
4. Dilley A., Drews C., Miller C., et al. Von Willebrand prevalence study. Acta Obstet Gynecol Scand
disease and other inherited bleeding disorders among 2006;85:200–6.
women diagnosed with menorrhagia. Obstet Gynecol 18. Chan S.S., Yiu K.W., Yuen P.M., et al. Menstrual prob-
2001;97:630–6. lems and health-seeking behaviour in Hong Kong
5. American College of Obstetricians and Gynecolo- Chinese girls. Hong Kong Med J 2009;15:18–23.
gists Committee on Adolescent Health Care, American 19. Claessens E.A., Cowell C.A. Acute adolescent menor-
College of Obstetricians and Gynecologists Commit- rhagia. Am J Obstet Gynecol 1981;139:277–80.
tee Gynecologic Practice. ACOG Committee opinion 20. Smith Y.R., Quint E.H., Hertzberg R.B. Menorrhagia
no. 451: Von Willebrand disease in women. Obstet in adolescents requiring hospitalization. J Pediatr Adolesc
Gynecol 2009;114:1439–43. Gynecol 1998;11:13–5.
6. Demers C., Derzko C., David M., et al. Prise en charge 21. Read G.F., Wilson D.W., Hughes I.A., et al. The use of
gynécologique et obstétricale des femmes présentant une salivary progesterone assays in the assessment of ovarian
coagulopathie héréditaire. Directive clinique de la SOGC function in postmenarcheal girls. J Endocrinol
n° 163, juillet 2005. J Obstet Gynaecol Can 1984;102:265–8.
2005;27:707–32. 22. van Hooff M.H., Voorhorst F.J., Kaptein M.B., et al. Pre-
7. Classens E.A., Cowell C.A. Acute adolescent menor- dictive value of menstrual cycle pattern, body mass
rhagia. Am J Obstet Gynecol 1981;139:277–80. index, hormone levels and polycystic ovaries at age 15
8. Kirtava A., Drews C., Lally C., et al. Medical reproduc- years for oligo-amenorrhoea at age 18 years. Hum
tive and psychosocial experiences of women diagnosed Reprod 2004;19:383–92.
with von Willebrand’s disease receiving care in 23. Mikhail S., Varadarajan R., Kouides P. The prevalence
haemophilia treatment centres: a case-control study. of disorders of haemostasis in adolescents with men-
Haemophilia 2003;9:292–7. orrhagia referred to a haemophilia treatment centre.
9. Kingman C.E., Kadir R.A., Lee C.A., et al. The use of Haemophilia 2007;13:627–32.
the levonorgestrel-releasing intrauterine system for 24. Jayasinghe Y., Moore P., Donath S., et al. Bleeding dis-
treatment of menorrhagia in women with inherited orders in teenagers presenting with menorrhagia. Aust
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10. Ong Y.L., Hull D.R., Mayne E.E. Menorrhagia in von 25. Oral E., Cagdas A., Gezer A., et al. Hematological ab-
Willebrand disease successfully treated with single dose normalities in adolescent menorrhagia. Arch Gynecol
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11. DiMichele D.M., Hathaway W.E. Use of DDAVP in in- 26. Bevan J.A., Maloney K.W., Hillery C.A., et al. Bleed-
herited and acquired platelet dysfunction. Am J Hematol ing disorders: a common cause of menorrhagia in
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surgical candidates. J Am Assoc Gynecol Laparosc 2007. Intrauterine device and adolescents. Obstet
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29. Gold M.A., Duffy K. Extended cycling or continuous intrauterine device in New Zealand adolescents. Con-
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REAFFIRMED SOGC CLINICAL PRACTICE GUIDELINE

No. 292-Abnormal Uterine Bleeding in

This clinical practice guideline has been prepared by the

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INTRODUCTION significantly affect quality of life,3 result in time off work,4

The following guidelines provide a review of the current

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AUB may be defined as any variation from the normal men-

Classic descriptions of AUB are based on the cyclicity and

Table 1.2. Definitions of terms for uterine bleeding

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In addition, pathologies of the myometrium, cervix, tubes,

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Figure. Management of AUB due to fibroids.

AUB Fibroids Myomectomy

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A number of randomized controlled trials have been per- Hysterectomy

Recommendations The management of fibroids may include medical suppres-

Clinical Tip Clinical Tips

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Maintenance treatment The etiology of AUB in adolescents has a similar differen-

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Summary Table Of Medical Treatments For Abnormal Uterine Bleeding

Treatment Dose/Regimen Mechanism Contraindications Adverse effects Efficacy/Benefits Contraception

No. 292-Abnormal Uterine Bleeding in Pre-Menopausal Women

REFERENCES 14. DeVore G.R., Owens O., Kase N. Use of intravenous

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