What is the treatment for irregular menstrual bleeding?

Treatment for Irregular Menstrual Bleeding

The most effective first-line treatment for irregular menstrual bleeding is NSAIDs for 5-7 days during bleeding episodes, while hormonal methods such as combined oral contraceptives can be used for long-term management if no underlying pathology is found. 1, 2

Initial Assessment and Management

Rule Out Serious Causes

• Exclude pregnancy, structural abnormalities, or malignancy before attributing bleeding to hormonal causes 3
• Consider endometrial biopsy for:
  • Women 35 years or older with recurrent anovulation
  • Women younger than 35 with risk factors for endometrial cancer
  • Women with excessive bleeding unresponsive to medical therapy 4

Immediate Management for Active Bleeding

1. NSAIDs (first-line):

   • Ibuprofen, naproxen, or mefenamic acid for 5-7 days during bleeding episodes
   • Reduces menstrual blood loss by 26-60% 2

2. For heavy or prolonged bleeding:

   • NSAIDs for short-term treatment (5-7 days)
   • Hormonal treatment with low-dose combined oral contraceptives for short-term treatment (10-20 days) if medically eligible 1

Long-Term Management Options

Hormonal Options (in order of effectiveness)

1. Levonorgestrel Intrauterine System (LNG-IUD):

   • Most effective option for menorrhagia (<1% failure rate)
   • First-line for women seeking both contraception and treatment for heavy bleeding 2
   • Can be inserted anytime during menstrual cycle if pregnancy is excluded 2

2. Combined Oral Contraceptives (COCs):

   • Effective for regulating cycles and reducing bleeding (5-9% failure rate)
   • Drospirenone-containing COCs particularly effective for dysmenorrhea 2
   • If started >5 days after menstrual bleeding began, use backup contraception for 7 days 1
   • For breakthrough bleeding on COCs:
     • Ensure correct pill use and timing
     • Consider changing to a higher estrogen content pill if needed 3

3. Progestin-Only Methods:

   • Progestin-only pills (5-9% failure rate)
   • Injectable DMPA (0.3-6% failure rate) - often leads to amenorrhea 2
   • For breakthrough bleeding:
     • Counseling and reassurance, especially in first 3-6 months
     • Supplemental estrogen during bleeding episodes 5

4. Tranexamic Acid:

   • Reduces menstrual blood loss by approximately 50%
   • Used for 4-5 days starting from first day of menstrual cycle
   • Contraindicated in women with active thromboembolic disease 2

Management Algorithm

1. First 3 months of hormonal contraceptive use:

   • Counseling and reassurance about expected irregular bleeding 1
   • Continue current method as bleeding typically improves with time

2. If bleeding persists beyond 3 months:

   • For COC users: Add supplemental estrogen and/or NSAIDs, or change to COC with higher estrogen content 5
   • For progestin-only method users: Add supplemental estrogen and/or NSAIDs during bleeding episodes 5

3. If bleeding remains unacceptable after treatment attempts:

   • Consider alternative contraceptive methods 1
   • Evaluate for underlying gynecological problems (interactions with medications, STDs, pathologic uterine conditions) 1

Special Considerations

• Contraindications to combined hormonal methods: Severe hypertension, complicated valvular heart disease, migraines with aura, history of thrombosis, or smoking in women over 35 2
• Drug interactions: Some medications may reduce contraceptive effectiveness 2
• Amenorrhea: Generally doesn't require treatment; provide reassurance unless the woman finds it unacceptable 1

Common Pitfalls to Avoid

1. Failing to rule out pregnancy or pathology before attributing bleeding to hormonal causes 3
2. Discontinuing hormonal contraception too early due to expected bleeding irregularities 1
3. Requiring unnecessary examinations before initiating contraception, creating barriers to access 2
4. Not providing adequate counseling about expected bleeding patterns, leading to method discontinuation 1
5. Overlooking coagulation disorders (like von Willebrand disease) in women with heavy menstrual bleeding 2

Remember that irregular bleeding in the first 3-6 months of hormonal contraceptive use is common and typically resolves with continued use. Proper counseling and reassurance can significantly improve method continuation rates.