Stable

No abnormalities are detected on abdominal and vaginal examination.

Transvaginal ultrasound scan reveals an endometrial thickness of 8 mm with no other abnormalities.

Haemoglobin percentage is 10 g/dl and the platelet count is within the normal range.

1. Administer combined oral contra ceptive pills for 3 cycles. 
2. Administer norethisterone 5 mg three times daily for 3 cycles.
3. Insert a levonorgestrel-releasing intrauterine device. 
4. Perform endometrial ablation. 
5. Perform an endometrial biopsy.

Levonorgestrel IUD

Since no structural or other abnormalities have been found, the bleeding is most probably due to ovulatory dysfunction, which is common in women over the age of 40 years. Insertion of a levonorgestrel releasing intrauterine device is the best option, as it will provide long-term treatment as well as effective contraception. Oral norethisterone can be used, but the woman has to take treatment regularly (or there will be breakthrough bleeding) and the treatment is short term. OCP is best avoided in women over the age of 35 years. Endometrial biopsy is not necessary as the endometrial thickness is normal on TVUS and there are no risk factors for endometrial carcinoma. It should be performed if medical treatment fails. Endometrial ablation is considered only if medical treatment fails.

Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 121:891–6.