Primary Care Management of Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is among the most common gynecologic complaints of reproductive-age women in ambulatory care settings. It is estimated to affect 11 to 13% of reproductive-age women at any given time. Prevalence increases with age, reaching 24% in women aged 36 to 40. Women generally present for care because the amount, timing, or other characteristics of the bleeding have changed from their individual norm. Population norms for menstrual bleeding, as established by 5th and 95th percentiles, are: Frequency of menses within a 24- to 38-day window; Regularity (i.e., cycle-to-cycle variation) within 2 to 20 days; Duration of flow from 4 to 8 days; Blood loss volume from 5 to 80 ml. Symptoms outside this normal range, or different from normal for the individual, can become problematic and deserve evaluation because they can warn of underlying conditions. Common problems include worry about the cause, embarrassment if the bleeding includes flooding-type bleeding with saturation of clothing, missed work and responsibilities, limitations of social activities and exercise, decreases or changes in sexual activity, and frustration with costs of sanitary protection. Collectively, the effects of troublesome bleeding reduce quality of life and drive desire for information about causes and treatment options. There is not a clear consensus on the clinical evaluation of a patient presenting with abnormal bleeding. Recommendations suggest that initial evaluation confirm the source and timing of bleeding, and exclude certain architectural etiologies (e.g., fibroids, polyps), cancer and precancerous changes in the cervix or uterus, coagulation defects, and systemic disease. The 2011 International Federation of Gynecology and Obstetrics (FIGO) classification recommends a structured history followed by uterine evaluation. In the research setting, the alkaline hematin method is the preferred technique for direct measurement of total menstrual blood loss (MBL). The pictorial blood loss assessment chart is a semi-quantitative tool for uniform reporting of bleeding as represented by the degree of saturation of sanitary pads and tampons. Diagnostic tools and evaluation strategies are not within the scope of this review; however, the review captures the operational definitions used by researchers and addresses applicability of the findings to contemporary practice. The literature reflects various management options for women with AUB with conflicting recommendations/summaries. Interventions of interest for this review include medical, complementary and alternative medicine, and behavioral/lifestyle interventions. This review is focused on the evidence available to inform selection of nonsurgical options to treat AUB with an emphasis on interventions that are accessible to and within the scope of usual practice for primary care practitioners in a clinical care setting. Key Questions addressed include: KQ 1A: What is the evidence for the effectiveness of medical, behavioral, and complementary and alternative medicine interventions (e.g., hormonal treatment, weight loss, or acupuncture) for improving short and long-term outcomes in women with irregular uterine bleeding? KQ 1B: What is the evidence for the effectiveness of medical, behavioral, and complementary and alternative medicine interventions (e.g., hormonal treatment, weight loss, or acupuncture) for improving short and long-term outcomes in women with abnormal cyclic uterine bleeding? KQ 2: What are the harms, including adverse events, associated with medical, behavioral, and complementary and alternative medicine interventions (e.g., hormonal treatment, weight loss, or acupuncture) in women with irregular uterine bleeding or abnormal cyclic uterine bleeding?