**9. Gonadotrophin-releasing hormone analogs**

The analogs of gonadotrophin-releasing hormone could be utilized as one of the approaches for the medical management of dysfunctional uterine bleeding. Gonadotrophin-releasing hormone modulators exert their action through their effect on the secretion of the gonadotropins, follicle-stimulating hormone and luteinizing hormone [26–32].

This action, in turn, suppresses the function of the ovaries and their hormone production of sex steroids, including that of estrogen and progesterone, with subsequent endometrial atrophy and improvement of hemoglobin levels [26–32].

Add-back therapy may be considered in cases of long-term use of gonadotrophinreleasing hormone analogs to prevent adverse effects on bone density and vasomotor symptoms without nullifying gonadotrophin-releasing hormone analogs' therapeutic effect.

A combination of both estrogen and progestin or progestin only have been prescribed as add-back therapy with gonadotrophin-releasing hormone analogs. Norethindrone acetate has been used as add-back therapy, as this unique progestin has both estrogenic and androgenic properties, that have been shown to be effective in reducing gonadotrophin-releasing hormone analogs' side effects [33, 34].

## **10. The anti-fibrinolytic tranexamic acid**

The anti-fibrinolytic tranexamic acid exerts its effect by blocking lysine binding sites on plasminogen. This prevents plasmin from acting with lysine *Alternatives to Hysterectomy for Dysfunctional Uterine Bleeding DOI: http://dx.doi.org/10.5772/intechopen.113758*

residues that affects the fibrin polymer, thus resulting in fibrin degradation in a reversible manner.

In a review that focused on the efficacy and safety of tranexamic acid in the treatment of idiopathic heavy menstrual bleeding, it was found that tranexamic acid was an effective therapy for heavy menstrual bleeding. It reduced menstrual blood loss by up to 60%, being significantly more effective than placebo, nonsteroidal antiinflammatory drugs, oral cyclical luteal phase progestins, or oral etamsylate [35].

Adverse effects of tranexamic acid are infrequent, with no evidence of an increase in thrombotic events that are related to its use [35].

An active thromboembolic disease or a history of thrombosis or thromboembolism or thrombophilia are considered contraindications for its use [35].

## **11. Levonorgestrel-releasing intrauterine system**

Regarding the utility of the levonorgestrel-releasing intrauterine system in the treatment of dysfunctional uterine bleeding and dysmenorrhea, a thorough and critical overview of previously published research found that that the insertion of a levonorgestrel-releasing intrauterine system was an effective modality in the long term [36].

The original idea for the insertion of a progestogen-releasing device inside the uterus was to utilize it as a long-term contraceptive method. The early devices were associated with unacceptable rates of ectopic pregnancies in cases of contraception failure. On the other hand, it was soon discovered that the system had other useful therapeutic applications, especially for the non-surgical treatment of dysfunctional uterine bleeding [36–39].

Furthermore, levonorgestrel-releasing intrauterine system (LNG-IUS) use in dysfunctional uterine bleeding and dysmenorrhea improves the quality of life, not only by the reduction of menstrual blood loss better than other medical therapies but also by reducing the extent of dysmenorrhea and pelvic pain. In addition, another benefit for some patients is the fact that the system is able to induce amenorrhea, thus eliminating heavy menstrual bleeding and associated dysmenorrhea in women of all ages, especially when contraception is required [39–42].

The levonorgestrel-releasing intrauterine system may be prescribed for anticoagulated patients presenting with dysfunctional uterine bleeding. This approach is associated with a significant reduction in blood loss and an increase in hemoglobin level after less than 6 months of therapy [43].

It has to be noted that with the use of the levonorgestrel-releasing intrauterine system to treat dysfunctional uterine bleeding in patients on anticoagulants, some may experience no improvement, or even experience worsening of their original heavy menstrual blood loss to an unacceptable degree [44].

Glanzmann thrombasthenia is a rare, inherited blood coagulation disorder characterized by defects in the platelet membrane glycoproteins IIb/IIIA. Symptoms of this disorder usually include abnormal bleeding, which may be severe. Female patients with this condition are often troubled with heavy menstrual bleeding [45].

Some adolescents with Glanzmann thrombasthenia have issues with heavy menstrual bleeding beginning at menarche. In a report by Lu and Yang, levonorgestrelreleasing intrauterine system for treatment of heavy menstrual bleeding in adolescents with Glanzmann's thrombasthenia was shown to be associated with a significant reduction of menstrual blood loss along with an improved quality of life [45].

Levonorgestrel-releasing intrauterine system is a potential alternative to other modalities that include anti-fibrinolytics, nonsteroidal anti-inflammatory drugs, and hormonal therapies that are effective, but could be associated with poor compliance.
