Dysfunctional uterine bleeding : medical treatment

Once all causes of abnormal uterine bleeding (AUB) have been excluded, medication should be considered as the first line treatment. Medication used in the treatment of dysfunctional uterine bleeding can be divided into hormonal and non-hormonal.

     Combined oral contraceptive pills (estrogen component + progesterone component) have been proven to reduce menstrual blood loss in heavy menstrual bleeding. The progesterone component acts by suppressing ovulation, thus inhibits ovarian production of estrogen and progesterone. This leads to absence of hormonal stimulation for endometrial proliferation and eventually this leads to endometrial atrophy. Meanwhile, the estrogen component of the COCP provides support to the endometrial lining of the endometrium to reduce the occurrence of irregular breakthrough bleeding/spotting. However it is contraindicated in certain conditions including history of thrombosis, stroke, uncontrolled hypertension, migraine with aura, coronary arterial disease, liver disease and history of breast cancer. These contraindications are mainly due to the estrogen component. Adverse effects include hormonal systemic effects such as breast tenderness, mood change and fluids retention. Rarely, it causes venous thromboembolism, stroke and coronary artery disease.

     Progesterone-only therapy includes progesterone-only pills, injected progesterone (DMPA) and LNG-IUS. The action is similar to progesterone component in COCP. However, since there is no estrogen component and no support to the endometrial lining, thus irregular breakthrough bleeding/spotting is more likely to occur. Common systemic  effects of progesterone include breast tenderness, weight gain, acne, water retention and headache .These systemic side effects are more prominent in progesterone-only pills and DMPA. However it is mild in LNG-IUS since this device is inserted into the uterus thus it administers high concentration of progesterone directly to the endometrium with only minimal amount of progesterone escaped into the systemic circulation. Other side effects of progesterone-only therapy,which is breakthrough bleeding as mentioned above, post insertion breakthrough bleeding is also common in LNG-IUS, but it is self limiting and it may be up to 6 months duration before it completely resolves. Other side effects of LNG-IUS are risk of expulsion, perforation and pelvic inflammatory disease. The risks of expulsion and perforation is partially operator dependent. Meanwhile, risk of pelvic inflammatory disease is more likely to occur in severely immuno-compromised patient and women with high risk of sexually transmitted infection.

GnRH agonist and Danazol are both proven to be effective in reducing menstrual blood loss. However, they may be used only as a short-term therapy (short-term usage of GnRH agonist pre-operatively), or for cases in which other medical or surgical therapies has failed or contraindicated (long -term usage of GnRH agonist, or Danazol). GnRH agonist is mainly associated with hypo-estrogenic side effects while Danazol is associated with androgenic effects.   

NSAIDs and tranaxemic acid is effective in reducing menstrual blood loss especially in ovulatory  bleeding. Tranaxemic acid is considered as the 1st line treatment for ovulatory dysfunctional uterine bleeding.

See

Dysfunctional uterine bleeding