What are the treatment options for ongoing menses (menstruation)?

Treatment Options for Ongoing Menstruation

For women experiencing heavy menstrual bleeding, NSAIDs such as ibuprofen (400mg every 4-6 hours as needed) are recommended as first-line treatment, though they are less effective than tranexamic acid or hormonal methods like the levonorgestrel IUD. 1

First-Line Treatments for Heavy Menstrual Bleeding

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

• Mechanism: Reduce prostaglandin levels which are elevated in women with heavy menstrual bleeding 2, 3
• Dosing: Ibuprofen 400mg every 4-6 hours as needed during menstruation 4
• Efficacy: More effective than placebo but less effective than tranexamic acid or hormonal methods 1
• Benefits: Also helps with dysmenorrhea (menstrual pain) 3
• Clinical pearl: Use the lowest effective dose for the shortest duration to minimize side effects 4

Tranexamic Acid

• More effective than NSAIDs for reducing heavy menstrual bleeding 2, 1
• Can be used in combination with NSAIDs for enhanced effect

Hormonal Treatment Options

Levonorgestrel Intrauterine System (LNG-IUD)

• Most effective hormonal option for heavy menstrual bleeding 5, 6
• Reduces bleeding significantly; many women experience light menstrual bleeding or amenorrhea over time 5
• Failure rate: 0.1-0.2% 6
• Counseling point: Unscheduled spotting or light bleeding is expected during the first 3-6 months of use 5

Combined Hormonal Contraceptives

• Effective for regulating menstrual cycles and reducing bleeding
• Failure rate: 5-9% with typical use 6
• Contraindications: Women over 35 who smoke, uncontrolled hypertension, history of VTE, stroke, or cardiovascular disease 6

Progestin-Only Methods

• Options include progestin-only pills, implants, or injectable contraception (DMPA)
• Failure rates:
  • Progestin-only pills: 5-9%
  • Implants: 0.05%
  • Injectable contraception: 0.3-6% 6
• Safety profile: Safer for women over 35 with contraindications to combined hormonal methods 6

Management Algorithm for Menstrual Bleeding Issues

1. For heavy menstrual bleeding:

   • Start with NSAIDs (ibuprofen 400mg every 4-6 hours during menses)
   • If inadequate response, consider adding tranexamic acid
   • For long-term management, consider LNG-IUD (most effective option)

2. For irregular bleeding with LNG-IUD:

   • Rule out underlying gynecological problems (IUD displacement, STDs, pregnancy, uterine pathology) 5
   • Provide reassurance that spotting/light bleeding typically improves within 3-6 months
   • If bleeding persists and is unacceptable, consider alternative contraceptive methods 5

3. For amenorrhea with LNG-IUD:

   • Reassurance that this is normal and doesn't require treatment 5
   • If amenorrhea is concerning to the patient, consider alternative methods 5

Important Clinical Considerations

• When using NSAIDs for menstrual bleeding, treatment should be initiated at the earliest onset of menses 4
• For women with contraindications to hormonal methods, the copper IUD is a highly effective non-hormonal option (failure rate 0.8%) 6
• Women experiencing abdominal pain, chest pain, shortness of breath, severe headache, vision changes, or severe leg pain/swelling while on hormonal treatments should seek immediate medical attention 6
• Regular blood pressure monitoring is recommended for women using combined hormonal contraceptives 6

Caveats and Pitfalls

• NSAIDs may interact with aspirin's antiplatelet activity when taken together 4
• Certain anticonvulsants, rifampin, and some HIV medications may decrease the effectiveness of hormonal contraceptives 6
• Heavy or prolonged bleeding with an LNG-IUD is uncommon and should prompt evaluation for underlying conditions 5
• Hormonal contraceptives do not protect against sexually transmitted infections; condoms should be recommended if STI protection is needed 6

The choice of treatment should be guided by the severity of bleeding, desire for contraception, medical contraindications, and patient preferences, with LNG-IUD offering the best long-term management for heavy menstrual bleeding.