Management Attention should be directed to establishing a cause of abnormal bleeding. In most cases, medical therapy is effective in managing abnormal bleeding and should be attempted before surgical management. Medical management with either oral contraceptives or progestogens is the preferred therapy of anovulatory bleeding in women of reproductive age (143). Progestinreleasing IUDs are effective in treating heavy menstrual bleeding and demonstrate comparable benefits for quality of life (181). It is argued that the IUD should be offered prior to consideration of hysterectomy, as there are comparable benefits on heavy menstrual bleeding and clear cost benefits (182). When medical therapy fails in women with anovulatory uterine bleeding and without the desire for future childbearing, the surgical options of endometrial ablation or hysterectomy can be considered. Endometrial ablation is an efficient and cost-effective alternative to hysterectomy, although this therapy may not be definitive, with increasing rates of repeat ablation and hysterectomy over time (143). In women with leiomyomas, hysterectomy provides a definitive cure. A variety of surgical alternatives to hysterectomy are available to women with symptomatic uterine leiomyomas.
Nonsurgical Management Most bleeding problems, including anovulatory bleeding, can be managed nonsurgically. Treatment with NSAIDs, such as ibuprofen and mefenamic acid, decreases menstrual ﬂow by 30% to 50%, but is less effective than tranexamic acid, danazol, or levonorgestrel IUD (93). Antifibrinolytics such as tranexamic acid were effective in reducing menstrual blood loss, and this indication was approved by the FDA in late 2008 (183).
Hormonal management of abnormal bleeding frequently can control excessive or irregular bleeding. The treatment of choice for anovulatory bleeding is medical therapy with oral contraceptives (143). Oral contraceptives are used clinically to decrease menstrual ﬂow, although supporting data from prospective clinical trials are sparse (184). Low-dose oral contraceptives may be used by reproductive-age women without medical contraindications and during the perimenopausal years in healthy nonsmoking women who have no major cardiovascular risk factors. The benefits of menstrual regulation in such women often override the potential risks. The medical treatment of acute abnormal bleeding in reproductive-age women is the same as that described for adolescents.