For patients in whom estrogen use is contraindicated, progestins, both oral and parenteral, can be used to control excessive bleeding. Cyclic oral medroxyprogesterone acetate, administered from day 15 or 19 to day 26 of the cycle, reduces menstrual ﬂow and offers no advantages over other medical therapies such as NSAIDs, tranexamic acid, danazol, or the levonorgestrel IUD; progestogen therapy for 21 days of the cycle reduces menstrual ﬂow, although women found the treatment less acceptable than the levonorgestrel IUD (97). The benefits of progestins to the patient with oligomenorrhea and anovulation include a regular ﬂow and the prevention of long intervals of amenorrhea, which may end in unpredictable, profuse bleeding. This therapy reduces the risk of hyperplasia resulting from persistent, unopposed estrogen stimulation of the endometrium. Depot formulations of medroxyprogesterone acetate are used to establish amenorrhea in women at risk of excessive bleeding. Oral, parenteral, or intrauterine delivery of progestins are used in selected women with endometrial hyperplasia or early endometrial cancer who wish to maintain their fertility (185). Continued monitoring is indicated. Danazol is effective in decreasing bleeding and inducing amenorrhea; it is used rarely for ongoing management of abnormal bleeding because of its androgenic side effects, including weight gain, hirsutism, alopecia, and irreversible voice changes. GnRH analogues are used for short-term treatment of abnormal bleeding, either alone or with add-back therapy consisting of combined estrogen/progestogen or progestogen alone (186).
Surgical Therapy The surgical management of abnormal bleeding should be reserved for situations in which medical therapy is unsuccessful or is contraindicated. Although sometimes appropriate as a diagnostic technique, D&C is questionable as a therapeutic modality. One study reported a measured reduction in menstrual blood loss for the first menstrual period only (187). Other studies suggest a longer-lasting benefit (188).
The surgical options range from a variety of techniques for endometrial ablation or resection to hysterectomy to a variety of conservative surgical techniques for management of uterine leiomyoma, including hysteroscopy with resection of submucous leiomyomas, laparoscopic techniques of myomectomy, uterine artery embolization, and magnetic resonance–guided focused ultrasonography ablation (see Chapters 23 and 24) (143,189). The choice of procedure depends on the cause of the bleeding, the patient’s preferences, the physician’s experience and skills, the availability of newer technologies, and a careful assessment of risks versus benefits based on the patient’s medical condition, concomitant gynecologic symptoms or conditions, and desire for future fertility. The assessment of the relative advantages, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research. Various techniques of endometrial ablation were compared with the gold standard of endometrial resection, and the evidence suggests comparable success rates and complication profiles (190). The advantages of techniques other than hysterectomy include a shorter recovery time and less early morbidity. However, symptoms can recur or persist; repeat procedures or subsequent hysterectomy may be required if conservative options are chosen. Additional studies that include quality-of-life outcomes will be helpful. Collaborative decision making, taking into account individual patient preferences, should follow a thorough discussion of options, risks, and benefits (191). Much is written about the psychologic sequelae of hysterectomy, and some of the aforementioned surgical techniques were developed in an effort to provide less drastic management options. Most well-controlled studies suggest that, in the absence of preexisting psychopathology, indicated but elective surgical procedures for hysterectomy have few, if any, significant psychologic sequelae (including depression) (see Chapter 12 and 24) (192,193).