From the Guidelines
Management options for large blood clots on Day 2 of menstruation should prioritize NSAIDs for short-term treatment, as recommended by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1. For immediate relief, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can reduce menstrual flow and pain by decreasing prostaglandin production. Key considerations include:
- Identifying and treating any underlying gynecological problems, such as interactions with other medications, STDs, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids) 1
- Using hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) as an alternative option 1
- Counseling on alternative contraceptive methods and offering another method if desired, especially if bleeding persists and is unacceptable to the woman 1 Non-medication approaches, such as applying heat to the lower abdomen, staying hydrated, and gentle exercise to improve circulation, can also be beneficial. However, for severe cases with very large clots or excessive bleeding, medical evaluation is necessary to rule out underlying conditions like fibroids, endometriosis, or bleeding disorders. In such cases, tranexamic acid may be prescribed for acute management of heavy bleeding, as it can help reduce menstrual blood loss by inhibiting fibrinolysis 1. Ultimately, the goal is to manage symptoms effectively while ensuring the woman's safety and addressing any underlying issues that may be contributing to the large blood clots.
From the Research
Management Options for Large Blood Clots on Day 2 of Menstruation
- Medical therapies are available to manage heavy menstrual bleeding (HMB) and large blood clots, including tranexamic acid, which has been shown to reduce menstrual blood loss by 26%-60% 2.
- The recommended oral dosage of tranexamic acid is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 2.
- Other medical therapies for HMB include hormonal treatments, such as levonorgestrel-releasing intrauterine system (LNG-IUS) and combined hormonal contraceptives, as well as haemostatic therapies like DDAVP (1-deamino-8-D-arginine) 3.
- In some cases, surgical interventions like endometrial ablation or hysterectomy may be necessary for women with severe HMB who have not responded to medical therapy 3.
- For women with underlying bleeding disorders, such as von Willebrand disease (VWD) or platelet function disorders, haemostatic agents like tranexamic acid and DDAVP may be effective in reducing menstrual blood loss 4.
- A study comparing the efficacy of ethamsylate, mefenamic acid, and tranexamic acid for treating menorrhagia found that tranexamic acid was the most effective treatment, reducing menstrual blood loss by 54% 5.
Assessment and Diagnosis
- Assessment of HMB should entail a menstrual and gynaecological history, a bleeding score, and a pelvic examination to rule out underlying pathology 3.
- A laboratory assessment for anemia, ovulatory dysfunction, and underlying bleeding disorders may also be necessary 6.
- Women with a personal or family history of bleeding, or those experiencing flooding and/or prolonged menses, should be referred to a hematologist for further evaluation 6.
Treatment Strategies
- Treatment strategies for HMB depend on the underlying cause, the woman's preference, and her fertility wishes 3.
- Medical therapies can be used in isolation or in combination with hormonal treatments, and haemostatic therapies may be used to enhance systemic and endometrial haemostasis 4.
- In some cases, factor concentrate administration during menses may be necessary to alleviate symptoms in women with severe underlying bleeding disorders 3.