This document summarizes treatment options for abnormal uterine bleeding (AUB). It discusses medical therapies like hormonal treatments, NSAIDs, and hemostatic agents as first-line options. Surgery is reserved for cases where medical therapy fails or is contraindicated. The treatment approach is individualized based on factors like age, symptoms, and any structural abnormalities. A PALM-COEIN framework is presented for guiding management based on identified causes of AUB. LNG-IUS is highlighted as an effective first-line treatment for many causes of AUB.

1. Overview of currently available
treatment options for AUB
“Evidence Based Management”
…Caring hearts, healing hands
Dr. Jyoti Agarwal
Dr Sharda Jain

2. Medical Therapy Surgical
•D&C
•Endometrial
Ablation
•Hysterectomy
Treatment
NSAIDHormonal
Therapy
•Oral Contraceptives
•Estrogen
•Progestin
Haemostatic
agents
•Aminocaproic acid
•Tranexamic Acid
•Desmopressin

3. Most cases of AUB can be treated medically
Surgery indicated only when medical therapy has
failed or is contraindicated

4. How well medical therapy works
Effectiveness Side effects Costs
Contraceptive Pill 50% +
Progestagens 30% + +
Danazol 100% + ++
GnRH`agonist 100% + + ++
NSAID 30% +
Antifibronilytic agents 50% + ++
IUD with Progesteron 70 %-97% + ++
Surgery is the last resort

5. Important to know that…..
• Dose of Tranexemic acid is 1000 mgm qid
• Tranexemic acid is more effective than NSAIDs
But both can be used together
• Either can be continued long term if effective
• Should be stopped if there is no response after 3 cycles
• Neither are contraceptive or cycle regulating
• NSAID is drug of 1st choice when there is
associated dysmenorrhoea

6. Treatment needs to be Individualized
Age , Parity , Symptoms , Fertility ,
Size , Number , Location of any structural abnormality

7. Management based on Acronym
PALM - COEIN

8. PALM-COEIN (POLYP)
• Hysteroscopy confirms the
diagnosis
• Remove it Hysteroscopicaly
• For recurrent & multiple
polyps, LNG – IUS to be
inserted
• Always send for HPE, if
malignant treat as, AUB -M
Single feeding vessel in polyp

9. PALM-COEIN (ADENOMYOSIS)
• Most difficult to treat
• LNG-IUS is first-line therapy
• Unwilling to use LNG-IUS, GnRH agonists with
add back therapy
COC’s, NSAIDs, Tranexemic acid

10. Add Back Therapy
• Estrogen and progesterone are given either sequentially
or combined so as to prevent osteoporosis
• Low dose Estrogen
– CEE (premarin ) 0.625 /0.3 mgm OD or
– Estradiol valerate 1 mgm OD for 30 days
• Low dose Progesterone
– Medroxy progesterone acetate 2.5 mgm OD for 30 days or 10
mgm OD for 10 days
– Norethisterone 1mg
– Micronised Progesterone 100 mg
• Tibolone (SERM) 2.5mgm OD

11. PALM-COEIN (Leiomyoma)

12. Needs removal
Does not require
our help
Small : medical Rx

14. PALM-COEIN (Leiomyoma)
• Medical management is offered for small (<4cm)
fibroids with tranexamic acid, COCs or NSAlDs
• LNG-IUS given if above treatment fails
Myomectomy reserved for large fibroid causing infertility

15. Chances of malignancy in fibroid is only 0.1 %

16. PALM-COEIN (Leiomyoma)
Uterine artery embolization
High intensity focused ultrasound (HIFU)
Newer promising options are
Ulipristal 5 mg daily for 3-4 months
Mifepristone 25mg daily for 4 months

17. Progesterone is needed for growth of fibroid
Ulipristal Acetate
• Is an anti-progesterone
• Reduces MBL by 90%
• Expensive
• Results are comparable to GnRHa
• May cause
fulminant hepatic
failure
Mifepristone (RU486)
• Mifepristone in low dose (5,10,
25 mg) daily for 3-6 months
decreases size of myoma by 50%
• There is no bone loss

18. PALM-COEIN (AUB – M)
Endometrial hyperplasia & malignancy
New WHO term 2014
Coexistent Invasive
Endometrial Cancer
Progression To
Invasive Cancer
Hyperplasia without
Atypia
<1% RR:1.01-1.03
Atypical Hyperplasia 25-33% RR:14-45
Revised classification of Endometrial hyperplasia WHO 2014

19. Reassurance Is most Essential

20. PALM-COEIN
Hyperplasia & Malignancy
• Women with endometrial hyperplasia without atypia
should be informed that the risk of progression to
endometrial cancer is less than 5% over 20 years
• Hyperplasia with atypia, hysterectomy is the
standard treatment
Reassurance Is most Essential

21. Endometrial Hyperplasia
Without Atypia
• LNG IUS is recommended as 1st line therapy
• If patient unwilling ,high dose Oral continuous
progestins
Medroxyprogesterone 10–20 mg/day or
Norethisterone 10–15 mg/day
• Cyclical progestogens should not be used because they are
less effective in inducing REGRESSION of endometrial
hyperplasia

22. Follow up of endometrial hyperplasia
• Treatment should be given for minimum of 6
months in order to induce histological
regression
• At least two consecutive 6-monthly negative
biopsies should be obtained
• Long-term follow-up should be considered with
annual endometrial biopsies life long

23. Hysterectomy is indicated if
• Progression to atypical hyperplasia occurs during follow-up
• No histological regression of hyperplasia despite 12
months of Rx
• Relapse of endometrial hyperplasia
• There is persistence of bleeding symptoms
• Non compliance

24. PALM-COEIN (Coagulopathy)
• Non-hormonal Rx with tranexamic acid (1 gm qid) as 1st line
• COCs/LNG-IUS as secondary option in consultation with a
haematologist
• Specific factor replacement or desmopressin in refractory cases in
consultation with haematologist
• NSAIDs are contraindicated as they can alter platelet function
• Intramuscular injections are avoided

25. PALM-COEIN (ovulatory)
• COCs are first-line therapy for 6-12 months
• Assess response after 1 year
• If COCs are contraindicated , LNG-IUS is
recommended

26. PALM-COEIN (ENDOMETRIAL)
Rx is same as AUB – O
(COC,s & LNG – IUS)

27. PALM-COEIN
Iatrogenic causes
• Rx is by withholding the
culprit drug
• Dose adjustment
needed in case of
anticoagulants
• If no alternatives are
available LNG-IUS is
recommended
I – Pill is the biggest culprit
List is endless

28. PALM-COEIN
Not otherwise classified
• Cesarean Scar Defects
• Pseudo-aneurysms
• Chronic Endometritis

29. LNG-IUS is first-line therapy
Significantly improves QoL
Reduces MBL by up to 70 % – 95%

30. PALM-COEIN
Not otherwise classified
• COCs are second line therapy
• Uterine Artery embolization for A-V malformations
• Hysterectomy is the last resort
GnRH agonists with add-back therapy , when medical treatment has
failed and surgical treatment is contra-indicated
Ablation has decreased due to availability of LNG-IUS
which works like medical ablation

31. Rx of AUB is Problem Oriented
Treatment needs to be strategized
• Mirena is great
• Medical therapy has a place
• Surgery is the last resort