Abnormal uterine bleeding (AUB) continues to be a top reason that women present for gynecologic care. In general, our approach to the management of AUB is to diagnose causes before we prescribe therapy and to offer conservative therapies initially and progress to more invasive measures if indicated.
In this Update, we highlight several new studies that provide evidence for preferential use of certain medical and surgical therapies. In considering conservative therapy for the treatment of AUB, we take a closer look at the efficacy of cyclic progestogens. Another important issue, as more types of endometrial ablation (EA) are being developed and are coming into the market, is the need for additional guidance regarding decisions about EA versus progestin-releasing intrauterine devices (IUDs). Lastly, an unintended consequence of an increased cesarean delivery rate is the development of isthmocele, also known as cesarean scar defect or uterine niche. These defects, which can be bothersome and cause abnormal bleeding, are treated with various techniques. Within the last year, 2 systematic reviews that compare the efficacy of several different approaches and provide guidance have been published.
Is it time to retire cyclic progestogens for the treatment of heavy menstrual bleeding?
Bofill Rodriguez M, Lethaby A, Low C, et al. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;(8):CD001016.
In a recent Cochrane Database Systematic Review, Bofill Rodriguez and colleagues looked at the efficacy, safety, and tolerability of oral progestogen therapy for heavy menstrual bleeding.1 They considered progestogen (medroxyprogesterone acetate or norethisterone) in short-cycle use (7 to 10 days in the luteal phase) and long-cycle use (21 days per cycle) in a review of 15 randomized clinical trials (RCTs) that included a total of 1,071 women. As this topic had not been updated in 12 years, this review was essential in demonstrating changes that occurred over the past decade.
The primary outcomes of the analysis were menstrual blood loss and treatment satisfaction. Secondary outcomes included the number of days of bleeding, quality of life, adherence and acceptability of treatment, adverse events, and costs.
Classic progestogens fall short compared with newer approaches
Analysis of the data revealed that short-cycle progestogen was inferior to treatment with tranexamic acid, danazol, and the 65-µg progesterone-releasing IUD (Pg-IUD). Of note, the 65-µg Pg-IUD has been off the market since 2001, and danazol is rarely used in current practice. Furthermore, based on 2 trials, cyclic progestogens demonstrated no clear benefit over nonsteroidal anti-inflammatory drugs. Additionally, long-cycle progestogen therapy was found to be inferior to the 52-mg levonorgestrel-releasing IUD (LNG-IUD), tranexamic acid, and ormeloxifene.
It should be noted that the quality of evidence is still lacking for progestogen therapy, and this study's main limitation is bias, as the women and the researchers were aware of the treatments that were given. This review is helpful, however, for emphasizing the advantage of tranexamic acid and LNG-IUD use in clinical care.
The takeaway. Although it may not necessarily be time to retire the use of cyclic oral progestogens, the 52-mg LNG-IUD or tranexamic acid may be more successful for treating AUB in women who are appropriate candidates.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Cyclic progestogen therapy appears to be less effective for the treatment of AUB when compared with tranexamic acid and the LNG-IUD. It does not appear to be more helpful than nonsteroidal anti-inflammatory drugs. We frequently offer and prescribe tranexamic acid, 1,300 mg 3 times daily, as a medical alternative to hormonal therapy for up to 5 days monthly for women without thromboembolism risk. Lukes and colleagues published an RCT in 2010 that demonstrated a 40% reduction of bleeding in tranexamic acid–treated women compared with an 8.2% reduction in the placebo group.2
Cyclic progestogen therapy appears to be less effective for the treatment of AUB when compared with tranexamic acid and the LNG-IUD. It does not appear to be more helpful than nonsteroidal anti-inflammatory drugs. We frequently offer and prescribe tranexamic acid, 1,300 mg 3 times daily, as a medical alternative to hormonal therapy for up to 5 days monthly for women without thromboembolism risk. Lukes and colleagues published an RCT in 2010 that demonstrated a 40% reduction of bleeding in tranexamic acid–treated women compared with an 8.2% reduction in the placebo group.2
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