Pharmacological therapies for the treatment of abnormal uterine bleeding are effective and generally well tolerated. This review presents an evidence-based approach to medical therapy. Selection depends on the etiology and amount of bleeding, need for contraception or preservation of fertility, perimenopause status, and medication efficacy and adverse effects.
Available nonhormonal agents include nonsteroidal anti-inflammatory agents, which reduce bleeding by 25% to 35% and improve dysmenorrhea through reduced prostaglandin levels; tranexamic acid, which inhibits plasminogen activator with a 40% to 60% reduction in menstrual blood loss; and intranasal desmopressin, which is an antifibrinolytic for women with an underlying bleeding disorder (eg, von Willebrand disease).
Hormonal regimens cause the inhibition of endometrial growth. Cyclic progestogen therapy for 21 days results in a significant reduction in menstrual blood loss. Limited data suggest that oral contraceptives reduce menstrual blood loss by 40% to 50% with decreased breast tenderness and dysmenorrhea and a reduction in risk of uterine and ovarian cancer. The progestin-releasing intrauterine devices are effective up to 97% by 6 months and provide relief of dysmenorrhea and contraception. Long-acting progestogen injections produce amenorrhea and provide contraception but are associated with irregular spotting and reversible bone loss. Danazol leads to endometrial atrophy with a reduced menstrual loss; androgenic adverse effects may be lessened with lower doses or vaginal use. Gonadotrophin agonists lead to ovarian suppression and are used to shrink fibroids or the endometrium preoperatively but are limited by hypoestrogenic adverse events. Emergency use of parenteral conjugated estrogens has a 70% chance of stopping abnormal bleeding but an increased risk of thrombosis.
From the Department of Obstetrics and Gynecology, Division of Midlife Health, University of Virginia Health System, Charlottesville, VA.
Received November 14, 2010; revised and accepted January 25, 2011.
Funding/support: None reported.
Financial disclosure/conflicts of interest: JoAnn V. Pinkerton receives research support (fees to the University of Virginia) from Pfizer previously Wyeth, Depo Med and Endoceutics. She is a consultant (fees to the University of Virginia) for Teva, Amgen, Pfizer, Boelinger-Ingelheim, DepoMed, and NovoNordisk.
Presented at the Premeeting Symposium: "Abnormal Uterine Bleeding: Causality, Diagnosis & Management"; October 6, 2010.
Address correspondence to: JoAnn V. Pinkerton, MD, University of Virginia Health System, Box 801104, Charlottesville, VA 22908. E-mail: firstname.lastname@example.org