February 12, 2013

ABNORMAL UTERINE
BLEEDING
Dr. Susan Nagtalon
I.
II.
III.
IV.

V.

1.
2.
3.

Objectives
Normal Menstrual Cycle
Progesterone and PGs in Ovulatory Cycle
Abnormal Uterine Bleeding (AUB)
a.
Definition of terms
b.
Evaluation of AUB
c.
AUB Between Ages 30 and 50
d.
AUB in the Perimenopausal Period
e.
AUB in Adolescents
Summary

OBJECTIVES
Describe normal menstrual cycle
Determine etiology of abnormal uterine bleeding
(AUB)
Managing bleeding through medical options or
surgical options

NORMAL MENSTRUAL CYCLE

What are the factors that ensure the regularity of
menses? We have the interplay between the
hypothalamic-pituitary, the ovarian, and the
endometrial cycle. There are changes that in both
your sex steroids, estrogen and progesterone, and
they have corresponding influences on the ovarian
function and the endometrium. The purpose of
each cycle is to prepare the woman for pregnancy.
If pregnancy will not occur, menstruation ensues.
Mean age of menarche: 13 years
Mean age of menopause: 51 years
o Meaning, women have menses for 38 years
o This is compatible for Filipino women who
have menopause in an average of 50.5 years
Normal cycle length: 28 +/- 7 days
Normal flow: 4 +/- 2 days
Menstrual blood loss (MBL): 60 mL its going to
be difficult to quantify menstrual blood loss
because the amount is the patients perception. If
its abnormal, the woman would say that she
needs to change her pad every 2-3 hours and the
pads get very very heavy and increased if there is
significant passage of blood clots during the
menstrual period. On the average, women would
describe heavy flow during the 2nd day of the cycle
afterwhich the menstrual blood significantly
decreases. During the perimenopausal period, a
woman may complain with of amenorrhea
afterwhich they can have heavy flow.
Variation in Menstrual Cycle Pattern (Dr. Allan
Treloar, 1967)
He proved
that
cycles
may be
regular
postmenarche and just prior to menopause. The
reason for this is the variation in the length of the
follicular phase of the cycle
Most irregular in the 2 years post menarche and 3
years prior to menopause
Following 34 years of observation, carried out
before oral contraceptives became available.
Studied 32,000 women covering about 250,000
cycles.
MENSTRUATION PHASES

Progesterone P4 withdrawal the event that

precedes
menstruation.
When
you
have
progesterone withdrawal, endometrial epithelium
and stroma collapses. There is vasoconstriction of
the blood vessels and you have hypoxia resulting
to fragmentation of the superficial epithelium.
Along with this, you have upregulation of
inflammatory cells, MMPs and VEGF. (See figure
below) Because of these, there is fragmentation,
sloughing, and eventually menstruation.
After menses, the epithelium has significantly
thinned/ denuded (endometrial stripe ranges from
1 to 2 mm documented by ultrasound).
o

Approximately 2 days before menses, there is

dramatic increase in PMN lymphocytes that
migrate from the vascular system. This leukocytic
proliferation heralds the collapse of the
endometrial stroma and the onset of menstrual
flow. [Berek&Novaks]

Menstruation and Regrowth

In the latter part of the menstrual phase,
estrogen is responsible for healing, regenerating
and rebuilding of the endometrium. Estrogen will
develop the glands and stroma that comes from
the tuft of the blood vessel in the endometrial bed.
There is progressive development of both glands
and stroma as the proliferative phase is
completed.
o

The decidua basalis (deepest region of the

endometrium) does not undergo significant
proliferation but, instead, is the source of
endometrial regeneration after each menses.
[Berek&Novaks]

Transition
form
Proliferative
to
Secretory
Endometrium
The evidence that progesterone has started to
take
effect
-->
presence
of
subnuclear
vacuolization of the endometrial gland. And as the

level of your progesterone further increases post

ovulatory, the vacuoles will actually ascend into
the tips of the gland and some of the secretions
will enter the endometrial canal.
o

Within 48 to 72 hrs following ovulation, the onset of

progesterone produces a clear presence of
eosinophilic protein-rich secretory products in the
glandular lumen (the secretory phase of the
endometrium). [Berek&Novaks]

Midsecretory to Late Secretory Endometrium

Coincident with maximal stromal edema in the late
secretory phase, the spiral arteries become clearly visible
and then progressively lengthen and coil during the
remainder of the secretory phase. [Berek&Novaks]

Cessation of Menstruation
*Normal Hemostatic mechanisms:
1. Localized vasoconstriction
2. Platelet adhesion
3. Formation of platelet plug
4. Reinforcement of platelet plug with fibrin
5. Removal of coagulated material by
fibrinolytic mechanisms
REMEMBER!!
What
are
the
important
mechanisms
that
cause
cessation
of
menstruation?
Platelet
plug
and
vasoconstriction. Both of these are related to
normal levels of your progesterone and its influence
on prostaglandin.
PROGESTERONE AND PGs IN OVULATORY
CYCLES
A normal ratio between your PGF2 and PGE2 is a
responsibility of your progesterone. PGF2 is
responsible for vasoconstriction and your
PGE2 is for vasodilation. You need more of your
vasoconstricting effect to cause cessation of
menstrual bleeding.
Endometrial PGF2/PGE2 ratio steadily increasing
from midcycle to menses
o PGF2 binds to receptors in the spiral arteries in
the
late
secretory
phase
to
cause
vasoconstriction and control menstrual flow.
o Decreased PGF2 causes heavier or prolonged
menstrual bleeding. An example is patients
who are anovulatory, which can be due to an
inadequate amount of progesterone therefore
decreasing the PGF2/PGE2 ratio.
ABNORMAL UTERINE BLEEDING (AUB)
What is the burden of the problem? Most of the
patients who have abnormal menstrual bleeding
either have heavy menses, out of cycle menses, or
change in the menstrual pattern. And this you see in
women who are in extreme ages. Although women in
reproductive ages may have abnormal menstrual

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pattern but this is usually related to ovulation

dysfunction.
DEFINITION OF TERMS
From FIGO Menstrual Disorders Working Group

Acute AUB - an episode of bleeding in a woman of

reproductive age, who is not pregnant, that is of
sufficient
quantity
to
require
immediate
intervention to prevent further blood loss.
You can say that there is acute AUB if the woman
complains of heavy menses to the point that her
vital signs are affected and in this case, she needs
immediate intervention. Otherwise, she will have
another bleeding and may develop anemia with
just one episode of heavy menstrual bleeding. This
is an EMERGENCY!
Chronic AUB - bleeding from the uterine corpus
that is abnormal in duration, volume. Regularity
and/or frequency and has been present for the
majority of the last 6 months. Can be managed as
an outpatient.
Acute Heavy Menstrual Bleeding
o A subgroup of acute abdominal uterine bleeding
o Relatively common clinical condition
Source of distress for patients
Challenge for health care providers
Substantial claim on health care resources

ACUTE
1.
2.
3.

EVALUATION OF AUB
HMB (heavy menstrual bleeding)
History and PE
Laboratory investigation
Uterine assessment
a. Histological assessment
b. Ultrasound imaging
i. Transvaginal ultrasound
ii. Saline infusion sonography
c. Hysteroscopy
d. Myometrial evaluation

Diagnosing heavy menstrual bleeding

Detailed history - you have to find out what the
cyclicity is as far as her menses is concerned, how
much bleeding she has, have there been a change
compared to her previous menstrual cycle, what
was the predisposing factor like medications
(aspirin, high dose estrogen withdrawal)
Character and nature of bleeding
Related symptoms
Family history - important for coagulation disorders
Contraceptive history and other medications
Co-morbid
factors
and
systemic
disease
(hypothyroidism
[0.3-2.5%],
cirrhosis,
hypoprothrombinemia) - cirrhosis because there is
decreased synthesis of your estrogen, while
hypoprothrombinemia
which
can
cause
coagulation defects.
PE in diagnosing Heavy menstrual bleeding
Physical examination performed to identify any
structural pathology or systemic disease
In PE, there are several findings that will tell you
that this is the likely cause of the bleeding. Chronic

cervicitis can be a factor because the surface of

the cervix becomes very sensitive and following
trauma, the patient can bleed (post-intimacy
bleeding). The same goes with your endocervical
polyps and of course cervical cancer. You will be
able to detect this if you do a very careful
speculum examination.

From L-R:

Cervical cancer;
Endocervical polyp and Cervicitis

Tests in diagnosing Heavy menstrual bleeding

Pregnancy test is a must for women in the
reproductive age group
Complete blood count (CBC) should be obtained
from all women with AUB; very helpful if there is
suspicion of a coagulation defect or to detect the
amount of anemia on patients who are with acute
or chronic menstrual bleeding.
o

The consensus report of an international expert

panel recommends measurement of CBC, platelet
count and function, PT, activated PTT, VWF, and
fibrinogen. [Berek&Novaks]

ultrasound suggests a thickening in any part of

endometrial lining; to know if it is an artifact or a
polyp
Hysteroscopy
Should be used as diagnostic tool only when
ultrasound results are inconclusive e.g to determine
the exact location of a fibroid or the exact nature of
an abnormality
Can be both diagnostic and therapeutic; already an
advanced intervention
Advantage over a blind procedure (D&C): in
hysteroscopy, you can target the defect and
remove it versus D&C wherein you can miss the
pathology
Endometrial Sampling
Should be performed to evaluate abnormal bleeding in
women who are at risk for endometrial pathology,
including polyps, hyperplasia, or carcinoma.
Mandatory in evaluation of anovulatory bleeding in
women older than 35 to 40 years of age, younger women
who are obese, and in those who do not respond to
medical therapy or those with a history of prolonged
anovulation.
Endometrial biopsy has largely replaced D&C.
[Berek&Novaks]

Ultrasound
First diagnostic tool for identifying structural
abnormalities especially if there are no findings in
speculum examination.
Best technique for evaluating the uterine contour,
endometrial
thickness,
[Berek&Novaks]

and

ovarian

structure.

Case examples where the patients history can

guide you to make a diagnosis even before you
undertake an ultrasound (all of the following present
with AUB P.A.L.E.M.):
1. Cervical Polyps - a patient with cervical
polyps may have several polyps inside the
endometrial cavity
2. Adenomyosis assocd w/ endometriosis - will
complain of heavy menstrual bleeding with a
progressive severe dysmenorrhea. So if she
ranks the pain, it would be increasing in
severity in adenomyosis. And on pelvic
exam, the uterus is symmetrically enlarged
with tenderness.
3. Leiomyoma both intramural myoma or
submucous myoma (uterus may not be
enlarged) may cause AUB; must be
protruding to the endometrium
4. Endometrial hyperplasia thickening of
endometrium due to estrogen effects;
presents with a long period of amenorrhea
then suddenly menstruates heavily usually
in patients on the background of intake of
hormones or increased body mass index
(greater than 35)
5. Endometrial Malignancy same history as
endometrial hyperplasia
SALINE INFUSION SONOGRAPHY- should not be
used as first line diagnostic tool but maybe useful
in providing a more accurate evaluation of the
uterus with intracavitary lesions; if findings of

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AUB was discussed accdg to AGE GROUP: Reproductive,

Perimenopausal & Adolescent

AUB BETWEEN AGES 30 and 50

Normal uterine cavity, 40%
Myomas, 30%
Polyps, 20%
Endometrial hyperplasia+ cancer, 10%

FIGO Classification of causes of abnormal uterine

bleeding in the reproductive years

PALM Structural problems that account for AUB

COeIN Nonstructural causes of AUB
Under Ovulatory dysfunction of COeIN:
Anovulatory bleeding - Most common cause of
abnormal uterine bleeding in reproductive age in
the absence of pathology. The reason for this is
the absence of progesterone effect on the

endometrium thats why there is progressive

development of the endometrium (proliferative). It
gets thicker and thicker until the time the limit has
been reached and theres going to be prolapse in
some areas (different points) of the endometrial
body hence bleeding is prolonged.
Ovulatory AUB: have decreased PGF2 /PGE2
ratio; Altered endometrial hemostasis due to
deficiencies in vasoconstrictors entholin1 and
PGF2a and/or accelerated lysis of endometrial clot
because of excess production of plasminogen
activator and increased local production of
vasodilatory PGE2 and prostacyclin
Absent or delayed follicular development
(not discussed)

Factor

Prevalenc
e
4.9%
12.7%

All patients
Weight >90kg
Age >45 yr
Weight >90kg and
age >45yr
Weight >90kg and
age <45yr
Family history of
colon cancer
Infertility
Nulliparity
Family history of
endometrial cancer

7.9%
22.2%

Odds ratio
and 95% CI
5.5 (2.910.6)
3.1 (1.6-6.1)
-

p
value
<
0.0001
0.0016
-

2.3%

5.0 (1.319.1)
3.6 (1.3-9.9)
2.8 (1.1-7.2)
5.8 (1.128.6)

0.0182

0.0127
0.0267
0.0392

MANAGEMENT OF AUB

No
ovultation

Mainly used for reproductive age group

MEDICAL MANAGEMENT
Goals of Therapy:
Desirous of regular periods it is best to give
progestin because you give it on day 14-27 and
then allow bleeding after its withdrawal
Desirous of contraception combined OCP is
helpful. IUD is recommended if patient finds
combined OCP inconvenient. (please refer to last page

No corpus
luteum

No
Progesteron
e
No
Secretory
Phase

for
table
of
contraception)

pharmaceutical

treatments

under

Desirous of pregnancy fertility drugs

Unopposed
estrogen

Emergency Care
Setting
Conjugated estrogens
25 mg IV q4hrs

Estrogen
breakdown bleeding

AUB IN THE PERIMENOPAUSAL PERIOD

Consider malignancy (AUB-M) first thing to
be ruled out! Ultrasound to assess
endometrium then biopsy agad!
Other causes: Atrophic vaginitis, Estrogen
replacement
Women who are taking hormone therapy during
menopause may be using a variety of hormonal regimens
that can result in bleeding. Unopposed estrogen therapy
may result in endometrial hyperplasia; hence progestins
are added in a continuous fashion.
Endometrial sampling is indicated in any unexpected
bleeding
that
occurs
with
hormonal
therapy.
[Berek&Novaks]

Endometrial biopsy is indicated in (remember!!)

o Any postmenopausal woman with bleeding of
premenopausal woman with HMB and/or irregular
vaginal bleeding
o Postmenopausal women with endometrial cells
seen on pap smear or premenopausal women
with atypical grandular or endometrial cells on
pap smear
o Breast CA patients on tamoxifen with AUB
Independent Risk Factors for Endometrial
Hyperplasia and Carcinoma in Women with AUB
(SOGC, 2011)

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Outpatient

Antifibrinolytics

Oral Progestins
MPA 60 120 mg po then
20 mg pot id for 7 days;
maintenance for 21 days
COCs

IV tranexamic acid 10 mg/kg

every 6-8 hours

Monopasic pot id 7 days; then

once daily for 21 days

or
Aminocaproic

Oral antifibrinolytic

acid

(Amicar) 4-5 gm. IV loading

then
1
gram/hour
maintenance

Tranexamic acid 2-3 gm. per

day; in divided dose

Succesful
medical
management
Chronic UB pathway

Failed
medical
management
Procedural management

EMERGENCY CARE Patient who comes in with

acute bleeding and changes in vital signs, ACUTE
AUB:
o First thing to do is establish a line because
patient may go into hypovolemia
o Take blood for CBC to find out if there is
coagulopathy, and
o To stop the bleeding, we give estrogen (IV high
dose) - the bleeding would be controlled in 6-8
hours but you have to maintain the patient in
high dose estrogen in at least 24 hours
o Along with this, we give your anti-fibrinolytics,
the most popular would be your tranexamic
acid (recommended dose is 3-4gms/24hrs for at
least 48 hours)
o If you have successfully controlled the bleeding,
you do not stop there, you can either shift the
patient to a combined OCP or you give the
patient progesterone (high dose) and
maintain this for about 3 weeks

 OUTPATIENT If the bleeding is CHRONIC, no

changes in vital signs or Hgb:
o You can give the patient either your oral
progestin in high dose or combined OCP.
Why is combined OCP always part of the
management? Because of its practicality
economical and readily available compared to
your progestin. Progestin is recommended if
there is contraindication for estrogen
o Oral antifibrinolytics is also part of therapy
o After we control the bleeding with high dose
progestin, we maintain the patient on
progesterone therapy from day 14-day 27 of
the cycle. You want to hold the endometrium and
allow bleeding when you withdraw progesterone
(simulate menstruation).

o Severe impact on quality of life

o Recommended for women who want to retain
uterus
Hysterectomy
o Not first line solely for HMB
o Consider when
- Other
treatments
have
failed,
are
contraindicated or declined
- Desire for amenorrhea
- Fully informed woman requests it
- No desire to retain uterus and fertility
o Decide route based on individual assessment
- First line: vaginal
- Second line: abdominal
- Consider laparoscopic vaginal hysterectomy in
morbidly obese/oophorectomy
- Do not remove healthy ovaries

Estrogen in Acute Bleeding

High dose estrogen therapy promotes rapid
endometrial growth & platelet adhesiveness to
cover denuded surfaces
Conjugated equine estrogens: orally at dosages up
to 10mg daily given in four divided doses
Once bleeding has slowed, patients can be
transitioned to an oral taper using combined oral
contraceptives (COCs)

AUB IN THE ADOLESCENT

In adolescents, first to rule out would be
coagulopathies and ovulatory dysfunction
related to immaturity of HPO.
Can also be due to psychogenic problems like
anorexia or bulimia.
The possibility of pregnancy must be considered!

Progestin Treatment
Cycle control with intermittent use of oral
progestins will also result in regular withdrawal
bleeding
Progestogen action on the endometrium
o Transforms estradiol to estrone, the not
biologically active form
o Promotes apoptosis of the endometrial cells
o Suppresses DNA synthesis
Additonal benefits of progestins
o Protection against endometrial hyperplasia and
cancer
o Luteal phase support and early pregnancy
support for select populations
o May be prescribed when estrogen is
contraindicated

Percentage of Ovulatory cycles in relation to

menarche - it was also the same finding of Treloar,
within 2 years of post-menarche, anovulatory
cycles may explain presence of AUB.

SURGICAL & RADIOLOGICAL TREATMENT

OPTIONS for women whose quality of life is
severely impacted [nice to know]
Endometrial ablation
o Severe impact on quality of life +no desire to
conceive +normal uterus +/- small fibroids (<3
diameter)
o Consider as first line only after full discussion of
risks and benefits
o Preferable to hysterectomy if uterus no bigger
than 10 week pregnancy
Uterine artery embolization (UAE)
o Fibroids (>3cm diameter) + severe impact on
quality of life
o Consider as first line if there are other significant
symptoms, pain or pressure
o Recommended for women who want to retain
uterus +/- avoid surgery
Hysteroscopic myomectomy
o Fibroid (>3cm diameter)

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Bleeding in pregnancy can be assocd with spontaneous

abortion,
ectopic
pregnancy,
molar
pregnancy.
[Berek&Novaks]

The younger the age of menarche, the sooner

regular ovulation is established. [Berek&Novaks]

Prevalence of Von Willebrand disease increased

in HMB - adolescents who have severe menorrhagia,
especially at menarche, should be screened for this.
[Berek&Novaks]

Management of Problematic Menstrual

Bleeding in Teenagers
Management is no different from reproductive age
group except for the maintenance therapy.

Hgb
gm/100ml

12

o reassurance
o menstrual
calendar
o iron
supplements
o periodic
re-evaluation

Hgb
10-12
gm/100ml

Hgb
gm/100ml

o reassurance
and
explanation
o menstrual
calendar
o iron
supplements
o cyclic
progestin
therapy or
oral
contraceptiv
es
o re-evaluation
in 6 months

o no active
bleeding
o explanation
o iron
supplements
o hormonal
therapy
o re-evaluation
in 6 months

o If very young, rule out HEMATOLOGIC problems

o If menopausal, rule out MALIGNANCY
o If reproductive age without any structural defect, rule out
PCOS or any ANOVULATORY CONDITIONS
o Once etiology is identified, then you can manage the
patient based on physiologic principles

10

Acute hemorrhage
Patients who are bleeding acutely but in a stable
condition and do not require hospital admission will
require doses of hormones higher than those in OCPs
use combination monophasic OCPs (q6hr, 4-7 days).
The decision to hospitalize depends on the rate of
recurrent bleeding and the severity of preexisting
anemia. [Berek&Novaks]
Transfusion
Fluid replacement therapy
Hormonal hemostasis (OC: estradiol valproate2-4

mg per day for 7-10 days; intravenous conjugated

estrogen)
Progestogen therapy for 7-10 days
Dilatation
and
curettage
when
hormonal
hemostasis fails not usually part of management
because it is unlikely that adolescents would have
malignancies unless the reason for abnormal
bleeding is related to a pregnancy-complication

Remember the effects of the drugs in endometrium!

Hormonal follow up treatment (Maintenance)

Continue with cyclic progestin for 10 days per
month, cycle days 15-24 to allow regular menses
Oral contraceptives

SUMMARY
COMMON CLINICAL SITUATIONS:
A 27y G1P1 who has
prolonged
heavy
menstrual bleeding for the
past 2 years
A 51y G3P2 (2012) with
continuous 10 days of
heavy bleeding
A 34y nulligravid with 3
weeks of heavy menstrual
bleeding
following
a
period of amenorrhea
A 15y with a Hb of 4g/dl
experiencing 7 days of
profuse menstruation

DETERMINE STRUCTURAL
PROBLEM AND MANAGE
ACCORDINGLY (reproductive
age)
ENDOMETRIAL BIOPSY,
SCREEN FOR MALIGNANCY
(perimenopause/menopausal)
MANAGE ACUTE AND LONG
TERM BLEEDING AND
MAINTENANCE THERAPY TO
PREVENT RECURRENCE
(reproductive age; likely due
to anovulatory dysfunction)
SCREEN FIRST FOR BLOOD
DYSCRASIA (young girl,
teenager)

Tranexamic antifibrinolytic; beneficial in women

w/ anovulatory cycles presenting with AUB
Estrogen (acute) repair & regenerate
endometrium through enhanced plt adhesiveness
and devt of stroma
Progesterone (long term) high dose; enhances
apoptosis of endometrial cells; transforms estradiol
to estrone; enhances transition from proliferative
to secretory phase (antimitotic helps because
patients may develop endometrial cancer d/t
hyperplasia)

TAKE HOME POINTS

Evaluate cause
o
Structural cause - PALM
o
Hormonal cause - COeIN
Treat acute cases
o
Volume
o
Anemia
o
Bleeding
Manage chronic cases according to profile
o
Desire for fertility
o
Desire for contraception
o
Minimize health risk [2013B]
***

SOURCES: PPT, recording; 2013B trans; Berek & Novaks

15th ed.
ETIOLOGY OF AUB RELATIVE TO AGE [2013 B]
Table 14.7 CAUSES OF BLEEDING BY APPROXIMATE FREQUENCY AND AGE GROUP [Berek and Novaks 15th ed.]
Infancy

Prepubertal

Adolescent

Reproductive

Perimenopausal

Maternal

Vulvovaginitis

Anovulation

Exogenous

Anovulation

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Postmenopaus
al
Atrophy

estrogen
withdrawal
Vaginal
foreign
body
Precocious
puberty

Exogenous
hormone use
Pregnancy

Pregnancy

Fibroids

Anovulation

Tumor

Coagulopathy

Fibroids

Cervical
endometrial
polyps
Thyroid
dysfunction

Cervical
and
endometrial polyps

and

Endometrial
polyps
Endometrial
cancer
Hormonal
therapy
Other tumor
vulvar, vaginal,
cervical

Thyroid dysfunction
Additional c/o Dra. Nagtalons PPT:
Sarcoma botryoides
(under Tumor)

Blood dyscrasia
(under Coagulopathy)
Hypothalamic
immaturity

Iatrogenic
(anticoagulation,
contraception,
hemodialysis)
Functional
(hypothyroid,
blood
dyscrasia,
luteal
dysfunction)

Inadequate
luteal
function
Psychogenic (including
anorexia and bulimia)

PHARMACEUTICAL TREATMENTS IN CONTRACEPTION

Note: Only Levenorgestrel-releasing IU system was discussed by Dr.

Nagtalon

Pharmaceutical
Treatment

How it works

Is it a
contracepti
on?

First Line

Levenorgestrelreleasing
intrauterine system

A device which
slowly releases
progestogen and
prevents
proliferation of the
endometrium. A PE
is needed before
fitting.

Yes

Will it
impact
on
future
fertilit
y?
No

Second
Line

Tranexamic acid
(non-hormonal)
Can be used in parallel
with investigations. If
no improvement, stop
treatment after 3
cycles
NSAID (non-hormonal)
If no improvement,
stop treatment after 3
cycles. Can be used in

Oral antifibrinolytic
tablets

No

No

Oral tablets that

reduce production
of prostaglandins

No

No

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Potential Unwanted Outcomes

experienced by some women

Common: irregular bleeding that may

last for over 6 months; hormonerelated problems such as breast
tenderness, acne or headaches if
present, are generally minor and
transient;
Less common: Amenorrhea
Rare: Uterine perforation at time of
insertion
Less common: Indigestion, diarrhea,
headache

Common: Indigestion, diarrhea

Rare: Worsening of asthma in
sensitive individuals, peptic ulcer
with possible bleeding and peritonitis

parallel with
investigations.
Preferred over
tranexamic acid in
dysmenorrheal.
Combined Oral
Contraceptives

Third Line

Oral progestogen
(norethisterone)
Injected
progestogen

Other

Gonadotrophinreleasing hormone
analogue (Gn-RH
analogue)
If used for more than 6
months, add-back HRT
therapy is
recommended

Oral tablets that

prevent
proliferation of the
endometrium

Yes

No

Oral tablets that

prevent
proliferation of the
endometrium
Intramuscular
injection that
prevents
proliferation of the
endometrium
Injection that stops
production of
estrogen and
progesterone

Yes

No

Yes

No

No

No

Common: Mood change, headache,

nausea, fluid retention, breast
tenderness
Very rare: Deep vein thrombosis,
stroke, heart attack
Common: Weight gain, bloating,
breast tenderness, headache, acne
(but usually minor and transient)
Rare: Depression
Common: Weight gain, irregular
bleeding, amenorrhea, premenstruallike syndrome including bloating, fluid
retention, breast tenderness)
Less common: Bone density loss
Common: Menopausal-like symptoms
(e.g., hot flushes, increased sweating,
vaginal dryness)
Less common: Osteoporosis
particularly trabecular bone with
longer than 6 months use

SOURCES: Lectures PPT and recording, 2013B trans, Berek & Novaks Gynecology 15 th ed.

Romar and Yessa

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