What is the initial workup and management for a patient with heavy intermenstrual bleeding lasting 30 days?

From the Guidelines

The initial workup for a patient with heavy intermenstrual bleeding lasting 30 days should include a thorough history, physical examination, pregnancy test, complete blood count, coagulation studies, and pelvic ultrasound, as recommended by the most recent guidelines 1.

Initial Assessment and Management

The management of heavy intermenstrual bleeding prioritizes addressing hemodynamic stability and anemia if present.

• A thorough history and physical examination are crucial to identify potential underlying causes.
• Laboratory tests such as a complete blood count and coagulation studies help assess the severity of bleeding and potential coagulopathies.
• Pelvic ultrasound is essential for identifying structural abnormalities like polyps, adenomyosis, leiomyoma, or malignancy.

Acute Management

For acute management, hormonal therapy is the mainstay of treatment.

• Combined oral contraceptives (COCs) can be initiated with one pill three times daily for 7 days, then twice daily for 7 days, followed by once daily for 21 days total.
• Alternatively, medroxyprogesterone acetate 10-20mg daily for 10-14 days can be used, as supported by recent guidelines 1.
• For patients with severe bleeding, tranexamic acid 1300mg orally three times daily for up to 5 days during bleeding can be added, as it has been shown to reduce bleeding symptoms in patients with fibroids 1.
• If anemia is present, iron supplementation (ferrous sulfate 325mg three times daily) should be initiated to improve hemoglobin levels and reduce the risk of further complications.

Additional Considerations

• NSAIDs like ibuprofen 600mg every 6 hours can help reduce bleeding and provide pain relief.
• Patients with hemodynamic instability or severe anemia (hemoglobin <7 g/dL) may require hospitalization for IV fluids, blood transfusion, and parenteral hormonal therapy.
• The approach aims to control bleeding by stabilizing the endometrium through hormonal regulation while investigating underlying causes such as structural abnormalities, endocrine disorders, coagulopathies, or malignancy that may require specific treatment once identified, in line with the PALM-COEIN classification system for uterine bleeding abnormalities 1.

From the Research

Initial Workup

The initial workup for a patient with heavy intermenstrual bleeding lasting 30 days involves a detailed history and pelvic examination, as well as laboratory testing that includes a pregnancy test and complete blood count 2.

Classification and Evaluation

The acronym PALM-COEIN facilitates classification of abnormal uterine bleeding, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified) 2.

Diagnostic Tests

• Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure 2.
• Transvaginal ultrasonography is the preferred imaging modality and is indicated if a structural etiology is suspected or if symptoms persist despite appropriate initial treatment 2.

Management Options

• Medical management is the preferred initial approach for hemodynamically stable patients, with options including oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid 2.
• The most effective long-term medical treatment for heavy menstrual bleeding is the levonorgestrel-releasing intrauterine system 2, 3, 4, 5.
• Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, nonsteroidal anti-inflammatory drugs, and depot medroxyprogesterone 2, 4, 5.
• Surgical options include hysterectomy, endometrial ablation, myomectomy, polypectomy, or uterine artery embolization 2.

Treatment of Heavy Menstrual Bleeding

• Tranexamic acid has been shown to be an effective treatment for heavy menstrual bleeding, reducing menstrual blood loss by 26%-60% 3, 6.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) also reduce heavy menstrual bleeding, but are less effective than tranexamic acid, danazol or the levonorgestrel-releasing intrauterine system 4, 5.