What is the next step for a patient experiencing menorrhagia (prolonged menstrual bleeding) for four weeks?

From the Guidelines

The patient experiencing menorrhagia for four weeks should seek immediate medical attention from a healthcare provider to rule out underlying health conditions and to initiate appropriate management. The patient should schedule an urgent appointment with their primary care physician, gynecologist, or visit an emergency department if the bleeding is severe with symptoms like dizziness or weakness.

Initial Evaluation and Management

Initial management may include:

• Hormonal therapy such as combined oral contraceptives (20-30 μg ethinylestradiol) 1
• Antifibrinolytic agents (e.g., tranexamic acid), 5 days 1
• Nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., celecoxib, ibuprofen, or mefenamic acid), 5–7 days 1
• Selective estrogen receptor modulators (SERMs) (e.g., tamoxifen), 7–10 days 1 Laboratory tests including complete blood count, pregnancy test, coagulation studies, and thyroid function tests will likely be ordered 1.

Further Evaluation

Pelvic ultrasound may be recommended to evaluate for structural causes such as uterine fibroids, polyps, or endometrial hyperplasia 1. Iron supplementation (e.g., ferrous sulfate) is often needed to address anemia from blood loss. Prolonged menorrhagia requires evaluation because it can indicate serious underlying conditions, and can lead to significant anemia if left untreated 1. It is crucial to explore patient goals, including continued method use or method discontinuation, and to consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions 1.

From the Research

Next Steps for Menorrhagia Treatment

For a patient experiencing menorrhagia (prolonged menstrual bleeding) for four weeks, the next recommended steps involve assessing the underlying cause and considering various treatment options.

• Assessment: A thorough menstrual and gynaecological history, a bleeding score, and a pelvic examination, including an ultrasound scan, are essential to rule out any underlying pathology 2.
• Medical Therapies:
  • Tranexamic Acid: An antifibrinolytic drug that reduces bleeding but may carry a risk of thrombosis, especially in non-severe bleeding cases 3.
  • Combined Oral Contraceptives (COCs): Effective in reducing menstrual blood loss and can be used as a first-line treatment for menorrhagia 4, 5, 6.
  • Levonorgestrel-releasing Intrauterine System (LNG-IUS): More effective than COCs in reducing menstrual blood loss but may have different satisfaction and adverse effect profiles 6.
• Comparison of Treatments:
  • Tranexamic Acid vs. COCs: Both are effective, but COCs may offer additional benefits like contraception and regulation of menstrual cycles 4.
  • COCs vs. LNG-IUS: LNG-IUS is more effective in reducing blood loss, but COCs might be preferred for their contraceptive benefits and ease of use 6.
• Considerations: The choice of treatment should consider the patient's age, presence of leiomyomas, desire for fertility, and potential side effects of the treatments 4, 2, 6.

Patient-Specific Considerations

• Age: Younger patients might respond better to certain treatments like COCs or tranexamic acid 4.
• Leiomyomas: Patients with leiomyomas might benefit more from COCs or other specific treatments 4.
• Desire for Fertility: Treatments that do not affect fertility, such as tranexamic acid, might be preferred in patients wishing to conceive.

Given the complexity and individual variability of menorrhagia, a healthcare provider should be consulted to determine the most appropriate next steps based on the patient's specific condition and medical history 2.