What medications can stop heavy uterine bleeding?

Medications for Heavy Uterine Bleeding

First-line medical treatments for heavy uterine bleeding include NSAIDs for 5-7 days during bleeding episodes, tranexamic acid for 4-5 days starting on the first day of bleeding, and hormonal contraceptives such as combined oral contraceptives or levonorgestrel IUD. 1

First-Line Treatment Options

NSAIDs

• NSAIDs (naproxen, mefenamic acid, ibuprofen) reduce menstrual blood loss by 26-60% when used for 5-7 days during bleeding episodes 1
• Particularly effective for copper IUD users with heavy bleeding
• Mechanism: Reduces prostaglandin production that contributes to excessive bleeding

Tranexamic Acid

• Reduces menstrual blood loss by approximately 50% 1
• Used for 4-5 days starting from the first day of menstrual cycle
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis
• Non-hormonal option for women who cannot use hormonal treatments

Hormonal Options

• Combined Oral Contraceptives (COCs)

  • Effective for short-term treatment (10-20 days) of heavy bleeding 1
  • Can be used for long-term management
  • Typical failure rate of 5-9%
  • If started more than 5 days after menstrual bleeding began, use backup contraception for 7 days

• Levonorgestrel Intrauterine Device (LNG-IUD)

  • Highly effective for heavy menstrual bleeding 2, 1
  • Typical failure rate of 0.1-0.2%
  • Provides long-term relief and contraception
  • First-line option for contraception and dysmenorrhea management

• Progestin-Only Pills

  • Can be started anytime, but if started more than 5 days after menses, use backup method for 2 days 1
  • Typical failure rate of 5-9%

Second-Line Treatment Options

GnRH Agonists and Antagonists

• Parenteral GnRH agonists (leuprolide acetate) and oral GnRH antagonists (elagolix, linzagolix, relugolix) 2
• Effective at reducing bleeding symptoms and tumor volume
• Often used for short courses to decrease fibroid size before surgery
• Side effects: hypoestrogenic effects (headaches, hot flushes, hypertension, bone mineral density loss)
• Combination treatment with low doses of estrogen and progestin can mitigate these symptoms

Intravenous Estrogen

• For acute, severe bleeding episodes 3, 4
• Rapidly controls bleeding
• Short-term use only
• Contraindicated in women with history of stroke, heart attack, blood clots, or liver problems

Management Algorithm for Heavy Uterine Bleeding

1. For acute, severe bleeding causing hypovolemia:

   • Consider intravenous estrogen therapy 4
   • Curettage may be indicated for patients with hypovolemia 4

2. For chronic heavy bleeding:

   • Start with NSAIDs for 5-7 days during bleeding episodes 2, 1
   • If ineffective, add tranexamic acid for 4-5 days starting on day 1 of bleeding 1, 5
   • For women needing contraception, consider hormonal options:
     • LNG-IUD (most effective, reduces bleeding by >90% after 12 months) 1, 5
     • Combined oral contraceptives (if no contraindications) 1
     • Progestin-only pills 1

3. For bleeding associated with uterine fibroids:

   • NSAIDs and tranexamic acid for short-term management 2
   • GnRH agonists/antagonists to reduce fibroid size and bleeding 2
   • Consider LNG-IUD if fibroids don't distort the uterine cavity 2, 1

Special Considerations

Bleeding with Hormonal Contraceptives

• For unscheduled spotting or light bleeding with LNG-IUD or implant users:
  • NSAIDs for 5-7 days 2
  • Hormonal treatment with COCs if medically eligible 2

Contraindications

• Combined hormonal methods are contraindicated in women with:
  • History of stroke or heart attack 3
  • Current or past blood clots 3
  • Current or past liver problems 3
  • Diagnosed bleeding disorders 3

Monitoring

• If bleeding persists despite treatment, evaluate for underlying conditions 2, 1
• Consider endometrial sampling in perimenopausal women due to higher risk of endometrial hyperplasia/cancer 1

Common Pitfalls to Avoid

1. Failing to rule out underlying pathology: Always consider organic causes of bleeding before attributing to hormonal imbalance 5

2. Inadequate treatment duration: NSAIDs and tranexamic acid must be used for the full recommended duration (5-7 days for NSAIDs, 4-5 days for tranexamic acid) to be effective 1

3. Ignoring bleeding disorders: Consider von Willebrand disease and other coagulation disorders in women with persistent heavy bleeding 4, 6

4. Thrombosis risk with treatment: Be cautious with tranexamic acid and hormonal treatments in women with risk factors for thrombosis 6

5. Expecting immediate results: Counsel patients that hormonal methods may cause irregular bleeding during the first 3 months of use before improvement occurs 1