What is the treatment for heavy vaginal bleeding?

Management of Heavy Vaginal Bleeding

First-line treatment for heavy vaginal bleeding should be tranexamic acid, which reduces menstrual blood loss by 20-60% and has the strongest evidence for effectiveness in controlling acute bleeding. 1

Initial Assessment and Stabilization

• Assess hemodynamic stability immediately:

  • Vital signs: blood pressure, heart rate, respiratory rate
  • Signs of hypovolemic shock: cool/clammy skin, altered mental status
  • Laboratory tests: hemoglobin, hematocrit, coagulation profile

• For hemodynamically unstable patients:

  • Establish IV access with large-bore catheters
  • Fluid resuscitation with crystalloids
  • Blood transfusion if hemoglobin <7 g/dL or ongoing severe bleeding
  • Monitor for hypofibrinogenemia, which is the biomarker most predictive of severe hemorrhage 2

Medical Management

First-line Treatments

1. Antifibrinolytics

   • Tranexamic acid: 1000-1500 mg orally 3-4 times daily during bleeding
   • Mechanism: Inhibits fibrinolysis, preserves clots
   • Reduces blood loss by 20-60% 1

2. NSAIDs

   • Mefenamic acid: 500 mg orally 3 times daily
   • Mechanism: Reduces prostaglandin levels
   • Reduces blood loss by 20-50% 1

3. Hormonal Options

   • Combined oral contraceptive pills: For acute bleeding control
   • Levonorgestrel intrauterine system (LNG-IUS): Most effective long-term option, comparable to surgical interventions 1
   • Cyclic oral progestogens: Less effective for women who ovulate regularly 1

For Heavy Menstrual Bleeding (HMB) Despite Combined Oral Contraceptives

1. Add tranexamic acid to COCP (53% of specialists recommend this approach) 2
2. If unsuccessful, consider levonorgestrel IUD (51% of specialists recommend this as second-line) 2
3. For refractory cases, consider combined DDAVP/COCP/TXA approach (34% of specialists recommend this as third-line) 2

Surgical Management

Consider when medical management fails or is contraindicated:

1. Uterine Ablation

   • Effective but has significant failure rates (up to 35% requiring hysterectomy within 10 years) 3
   • Not recommended for women desiring future fertility

2. Uterine Artery Embolization (UAE)

   • Cost-effective with fewer complications than hysterectomy
   • Causes >50% decrease in fibroid size at 5 years 3

3. Hysterectomy

   • Definitive treatment but has higher risks of severe complications
   • Consider as last resort when other treatments fail
   • Prefer minimally invasive approaches (vaginal or laparoscopic) over abdominal 3

Management of Acute Severe Bleeding

For massive hemorrhage requiring immediate intervention:

1. Resuscitative Measures

   • Activate massive transfusion protocol for uncontrolled bleeding
   • Maintain hematocrit >25%, platelet count >50,000, and fibrinogen >120 mg/dl 2

2. Mechanical Interventions

   • Pelvic packing for temporary control of severe bleeding 2
   • Consider balloon tamponade devices for compression 2

3. Pharmacological Interventions

   • Vasoactive drugs (terlipressin, octreotide) may be considered if bleeding is related to portal hypertension 2
   • Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2

Special Considerations

For Pregnant Patients

• Avoid terlipressin as it can cause uterine contractions and reduce uterine blood flow 2
• For variceal bleeding, use octreotide or somatostatin with cephalosporin antibiotics 2

For Patients with Liver Disease

• Maintain body temperature above 36°C and avoid acidosis 2
• Consider viscoelastic coagulation testing (thromboelastography) for rapid assessment 2

Common Pitfalls to Avoid

1. Delaying treatment while waiting for laboratory results in unstable patients
2. Underestimating blood loss based on patient's subjective assessment 1
3. Failing to consider structural causes (fibroids, polyps) in women over 40 years 1
4. Using cyclic progestogens alone in ovulating women (ineffective) 1
5. Neglecting to provide contraceptive counseling when using treatments that are not contraceptives 3

Remember that early, aggressive management of heavy vaginal bleeding prevents complications and improves quality of life. Medical management should be thoroughly evaluated before considering surgical interventions.