What are the treatment options for prolonged menses?

From the Guidelines

Prolonged menses can be treated with NSAIDs for short-term management, and if an underlying gynecologic problem is not found, hormonal treatment with low-dose COCs or estrogen can be considered for short-term treatment. The treatment options for prolonged menses should prioritize the patient's quality of life, morbidity, and mortality. According to the most recent and highest quality study 1, if clinically indicated, an underlying gynecological problem should be considered, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions.

Treatment Options

• NSAIDs for short-term treatment (5–7 days) can be considered for immediate management of prolonged menses, as recommended by 1 and 1.
• Hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) can be considered if an underlying gynecologic problem is not found, as stated in 1 and 1.
• If heavy or prolonged bleeding persists and the woman finds it unacceptable, counseling on alternative contraceptive methods and offering another method if desired is recommended by 1 and 1.

Key Considerations

• The underlying cause of prolonged bleeding should be investigated through blood tests, pelvic ultrasound, or endometrial biopsy, as treatment may need to address specific conditions like fibroids, polyps, or endometrial hyperplasia.
• Non-hormonal options, such as tranexamic acid and nonsteroidal anti-inflammatory drugs like ibuprofen, can be considered for patients who are not eligible for hormonal treatment.
• Surgical options, such as endometrial ablation or hysterectomy, may be considered if medical management fails, as mentioned in the example answer. However, the provided evidence 1 does not support this statement, and therefore, it should not be considered as a primary treatment option.

From the Research

Treatment Options for Prolonged Menses

• Tranexamic acid is an effective treatment for heavy menstrual bleeding, reducing menstrual blood loss by 34-59% over 2-3 cycles 2.
• Non-steroidal anti-inflammatory drugs (NSAIDs) are also effective in reducing heavy menstrual bleeding, but are less effective than tranexamic acid, danazol, or the levonorgestrel-releasing intrauterine system (LNG IUS) 3, 4.
• Combined oral contraceptives (COCs) are equally effective as oral tranexamic acid in reducing mean blood loss among patients with heavy menstrual bleeding, with no significant difference observed between the two groups 5.
• Other treatment options include oral progestogen, ethamsylate, and the progesterone-releasing intrauterine system (IUS), although the evidence for these options is limited and inconclusive 3, 4, 6.

Efficacy of Treatment Options

• Tranexamic acid is more effective than NSAIDs, oral progestogen, and ethamsylate in reducing menstrual blood loss 2, 3, 4.
• COCs are equally effective as oral tranexamic acid in reducing mean blood loss among patients with heavy menstrual bleeding, especially in younger age groups and in patients with leiomyomas 5.
• The efficacy of treatment options may vary depending on individual factors, such as age, presence of leiomyomas, and medical history 5.

Safety and Tolerability of Treatment Options

• Tranexamic acid is generally well-tolerated, with the most common adverse events being gastrointestinal in nature 2.
• NSAIDs may cause adverse events such as nausea, vomiting, diarrhea, and dyspepsia, although the incidence is generally low 3, 4.
• COCs may have hormonal side effects and may not be suitable for all patients, especially those with contraindications to estrogen therapy 6, 5.