Effective Strategies to Manage Acute Abnormal Uterine Bleeding

Introduction to Acute Abnormal Uterine Bleeding and Its Causes

Acute Abnormal Uterine Bleeding (AUB-a) is an urgent condition characterized by excessive menstrual bleeding that is not associated with pregnancy. This condition requires immediate medical intervention to prevent severe blood loss and potential hemodynamic instability. AUB-a can manifest either as an isolated incident or as a symptom of an underlying chronic issue that necessitates thorough evaluation and management (Van Voorhis et al., 2019).

The etiology of AUB-a is multifactorial, including structural abnormalities such as polyps and leiomyomas, hormonal imbalances, coagulopathies, and malignancies. The classification system PALM-COEIN categorizes causes of AUB into structural (Polyps, Adenomyosis, Leiomyomas, and Malignancy) and non-structural (Coagulopathy, Ovulatory dysfunction, Endometrial factors, Iatrogenic causes, and Not classified) (Munro et al., 2018). Understanding the nuances of these causes is essential for effective management and treatment.

Table 1: Most Prevalent Causes of AUB-a by Age

Clinical Evaluation and Diagnosis of AUB-a

The clinical evaluation of a patient presenting with AUB-a includes a thorough assessment of vital signs, hemodynamic status, and a detailed medical history. Vital signs are critical indicators; hypotension and tachycardia may signify significant blood loss. A complete blood count (CBC) can help assess the degree of anemia, with hemoglobin levels below 10 g/dL indicating severe blood loss (Munro et al., 2018).

Hemodynamic Assessment

The assessment of hemodynamic stability can be performed through the following:

• Pulse and Blood Pressure Monitoring: Hypotension and tachycardia could indicate hypovolemic shock.
• Urine Output: A low output may signal renal hypoperfusion due to low blood volume.

Gynecological Examination

A gynecological examination, including a speculum and bimanual examination, is essential for identifying any structural abnormalities. The speculum examination allows visualization of the cervix and vaginal walls, where lesions or polyps may be noted, while the bimanual exam assesses uterine size and any adnexal abnormalities (El-Hemaidi et al., 2021).

Medical Management Options for Acute Abnormal Uterine Bleeding

The medical management of AUB-a is primarily focused on stabilizing the patient and controlling bleeding. Treatment strategies can include hormonal therapies, antifibrinolytics, and non-steroidal anti-inflammatory drugs (NSAIDs).

Antifibrinolytics

Tranexamic acid is a first-line treatment for acute AUB-a. It is shown to reduce menstrual blood loss by 34% to 54% (Munro et al., 2013). Dosage recommendations include:

• Oral Administration: 1.5 g to 4 g per day.
• Intravenous Administration: 10 mg/kg every 8 hours for the duration of the bleeding episode.

NSAIDs

NSAIDs, such as mefenamic acid and ibuprofen, can also be effective in managing heavy menstrual bleeding by inhibiting prostaglandin synthesis. Typical dosages include:

• Mefenamic Acid: 500 mg every 8 hours.
• Ibuprofen: 800 mg every 8 hours.

Hormonal Treatments

Hormonal treatments are often utilized to manage AUB-a effectively. The most common options include:

• Combined Hormonal Contraceptives: These are effective in stabilizing the endometrial lining and preventing further bleeding.
• Progestogens: Medroxyprogesterone acetate or norethisterone can also be used, especially in cases of anovulation or when estrogen is contraindicated.

Hormonal Treatments: Combined Hormonal Contraceptives and Progestogens

Combined hormonal contraceptives (CHCs) can be administered to stabilize the endometrium and control bleeding. The doses should be tailored to the individual, often starting at higher doses and tapering down based on response.

Table 2: Recommended Dosages for Hormonal Treatments

Progestogens are particularly indicated when estrogen is contraindicated. The effectiveness of progestogens in controlling acute bleeding can be significant, leading to a reduction in menstrual blood loss.

Surgical Interventions for Acute Abnormal Uterine Bleeding

In some cases, surgical interventions may be necessary, particularly when medical management fails or if there is a structural cause of bleeding.

Dilation and Curettage (D&C)

D&C can be used for both diagnostic and therapeutic purposes. It allows for the treatment of uterine abnormalities while providing tissue for histopathological examination.

Uterine Artery Embolization (UAE)

UAE can be considered in cases of AUB-a due to fibroids or polyps, particularly for patients who wish to preserve their uterus.

Hysterectomy

Hysterectomy remains the last resort for women with AUB-a, particularly when medical management is ineffective or if there are significant underlying pathologies.

Conclusion

Acute Abnormal Uterine Bleeding is a significant clinical issue that requires prompt evaluation and management. The approach must be tailored to each patient’s unique situation, considering factors such as hemodynamic stability, underlying causes, and the patient’s reproductive desires. A multi-faceted treatment strategy that includes medical and surgical options is essential for optimal outcomes.

FAQ

What are the main causes of Acute Abnormal Uterine Bleeding?

• Causes include structural abnormalities (polyps and leiomyomas), hormonal imbalances, coagulopathies, and malignancies.

How is Acute Abnormal Uterine Bleeding diagnosed?

• Diagnosis involves patient history, physical examination, blood tests, and imaging studies such as ultrasound.

What are the first-line treatments for AUB-a?

• Antifibrinolytics such as tranexamic acid and hormonal treatments like combined oral contraceptives are first-line treatments.

When is surgical intervention necessary for AUB-a?

• Surgical options are considered when medical management is ineffective or if there are significant structural abnormalities causing the bleeding.

References

1. El-Hemaidi, I., Gharaibeh, A., & Shehata, H. (2021). Diagnosis and management of acute abnormal uterine bleeding during menacme. Clinics (Sao Paulo), 76. https://doi.org/10.1016/j.clinsp.2025.100608

2. Munro, M. G., Critchley, H. O., & Fraser, I. S. (2018). The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet, 143(3), 393–408

3. Van Voorhis, B., & Santoro, N. (2019). ACOG Committee opinion no 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol, 121(4), 693–701