What are the treatment options for prolonged menstrual bleeding?

Treatment Options for Prolonged Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line medical treatment for prolonged menstrual bleeding, reducing blood loss by 71-95% and providing comparable efficacy to endometrial ablation. 1

Initial Assessment and Evaluation

Before initiating treatment, it's essential to:

• Rule out underlying gynecological problems (IUD displacement, STIs, pregnancy, pathologic uterine conditions)
• Differentiate between anovulatory and ovulatory bleeding patterns
• Consider hemodynamic stability (bleeding that saturates a large pad/tampon hourly for ≥4 hours warrants urgent evaluation)
• Test for pregnancy in all reproductive-age women with abnormal uterine bleeding

Treatment Algorithm Based on Bleeding Pattern and Patient Factors

First-Line Treatments:

1. Levonorgestrel-releasing IUD (LNG-IUD):

   • Most effective option (71-95% reduction in menstrual blood loss)
   • Comparable efficacy to endometrial ablation
   • Provides contraception while treating bleeding
   • Main effect is at endometrial level with minimal systemic absorption 2, 1

2. NSAIDs:

   • For 5-7 days during bleeding days
   • Reduce menstrual blood loss by 26-60%
   • Options include mefenamic acid, naproxen, ibuprofen, flufenamic acid, diclofenac sodium
   • Particularly effective for copper IUD users with heavy bleeding 2, 1

3. Combined Hormonal Contraceptives:

   • Oral or transvaginal options
   • Second-choice after LNG-IUS for women not seeking pregnancy
   • Induces regular shedding of a thinner endometrium 1, 3

4. Tranexamic Acid:

   • Dosage: 3.9-4g/day for 4-5 days starting from first day of menstrual cycle
   • Reduces menstrual blood loss by approximately 50%
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2, 1
   • Should generally be avoided in women with SCAD (spontaneous coronary artery dissection) 2

5. Oral Progestins:

   • Norethindrone acetate: 5-10mg daily for 5-10 days to produce secretory transformation of endometrium 4
   • For chronic management: 2.5-15mg daily (start with 5mg, increase by 2.5mg every two weeks as needed) 4
   • Cyclic oral progestin treatment can reduce bleeding by 87% 2
   • Long-course oral progestogens (≥3 weeks per cycle) are more effective than short-course (≤14 days) 3

Second-Line/Surgical Options:

1. Endometrial Ablation:

   • Second-generation techniques (thermal balloon, microwave, radiofrequency)
   • More effective than oral medical treatments for long-term management
   • Particularly useful for women who want to avoid hormonal treatments 2, 5

2. Polypectomy or Fibroidectomy:

   • When structural causes are clearly identified
   • Targeted removal of polyps or fibroids causing bleeding 5

3. Uterine Artery Embolization:

   • Alternative to surgery for fibroids
   • Preserves the uterus 5

4. Hysterectomy:

   • Most definitive treatment
   • Reserved for when other treatments fail or when significant pathology exists 5

Special Considerations

• Antiplatelet Therapy: If patient is on antiplatelet therapy, reassess the indication and discontinue if appropriate, as these medications can exacerbate bleeding 2

• Cardiovascular Disease: Women with cardiovascular disease should avoid combined hormonal methods and generally use transdermal systemic agents if hormone therapy is needed 2, 1

• Perimenopausal Women: Consider LNG-IUD, which can manage heavy bleeding while providing endometrial protection during perimenopause 1

• Anovulatory Bleeding: May require different management approach, including endometrial biopsy for women ≥35 years with recurrent anovulation or those with risk factors for endometrial cancer 5

Common Pitfalls to Avoid

• Don't assume bleeding is normal with LNG-IUD; heavy bleeding is uncommon and warrants evaluation 1
• Don't use aspirin for treatment, as it has not shown benefit and may increase blood loss 1, 6
• Don't ignore persistent bleeding despite treatment, as it may indicate underlying pathology requiring further evaluation 1
• Don't underestimate the effectiveness of LNG-IUS, which is comparable to surgical interventions for many women 1, 3

By following this evidence-based approach to managing prolonged menstrual bleeding, clinicians can significantly improve patients' quality of life while minimizing morbidity associated with excessive blood loss and unnecessary surgical interventions.