Treatment of Abnormal Uterine Bleeding
The risks to a woman with anovulatory uterine bleeding include anemia, incapacitating blood loss, endometrial hyperplasia, and carcinoma. Uterine bleeding can be severe enough to require hospitalization. Both hemor rhage and endometrial hyperplasia can be prevented by appropriate management.
The primary goal of treatment of anovulatory uterine bleed-ing is to ensure regular shedding of the endometrium and conse-quent regulation of uterine bleeding. If ovulation is achieved,conversion of the proliferative endometrium into secretory endometrium will result in predictable uterine withdrawal bleeding.
A progestational agent may be administered for a mini-mum of 10 days. The most commonly used agent is me-droxyprogesterone acetate. When the progestational agent is discontinued, uterine withdrawal bleeding ensues, thereby mimicking physiologic withdrawal of progesterone.
As an alternative, administration of oral contraceptives suppresses the endometrium and establishes regular, pre-dictable withdrawal cycles. No particular oral contraceptive preparation is better than any of the others for this purpose. Women who take oral contraceptives as treatment of abnormal uterine bleeding often resume abnormal uterine bleeding after therapy is discontinued.
If a patient is being treated for a particularly heavy bleeding episode, once organic pathology has been ruled out, treatment should focus on two issues: (1) control of the acute episode, and (2) prevention of future recurrences. Both high-dose estrogen and progestin therapy as well as combination treatment (oral contraceptive pills, four per day) have been advocated for management of heavy abnor-mal bleeding in the acute phase. Long-term preventive management may include either intermittent progestin treatment or oral contraceptives. Uterine bleeding that does not respond to medical therapy often is managed sur-gically with endometrial ablation or hysterectomy. Before proceeding with endometrial ablation, one must rule out endometrial carcinoma.
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