What can help control heavy vaginal bleeding?

Management of Heavy Vaginal Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line medical therapy for controlling heavy vaginal bleeding, reducing blood loss by up to 80-90% in most women. 1, 2

Diagnostic Approach

Before initiating treatment, it's important to identify the underlying cause:

• Transvaginal ultrasound is recommended as the first-line imaging study to assess:
  • Endometrial thickness
  • Structural causes (polyps, fibroids, polycystic ovaries) 1
• Laboratory testing should include:
  • Complete blood count (to assess for anemia)
  • Pregnancy test (to rule out pregnancy-related bleeding)
  • Hormonal assessment if indicated (LH, FSH, thyroid-stimulating hormone, prolactin) 1
• Rule out malignancy in persistent or recurrent abnormal bleeding 3

Treatment Options (In Order of Effectiveness)

1. Hormonal Methods

• Levonorgestrel-releasing IUD (LNG-IUS)

  • Most effective medical treatment for heavy menstrual bleeding 1, 2
  • Effective for both functional bleeding and bleeding due to structural causes (fibroids, adenomyosis) 2
  • Approximately 50% of users experience amenorrhea or oligomenorrhea by 2 years 1
  • Failure rate of only 0.1-0.2% 1

• Combined hormonal contraceptives (oral, patch, or vaginal ring)

  • Second-line option when LNG-IUS is not suitable 2
  • Effective for regulating cycles and reducing bleeding 1
  • Contraindicated in women over 35 who smoke and those with specific cardiovascular risk factors 1

• Cyclic progestin therapy

  • Long-course (≥3 weeks per cycle) is more effective than short-course 2, 4
  • Example: medroxyprogesterone acetate 10mg daily for 10-14 days each month 1
  • Less effective than LNG-IUS or combined hormonal methods 2

2. Non-Hormonal Methods

• Tranexamic acid

  • Antifibrinolytic that reduces menstrual blood loss by 20-60% 5
  • Taken only during menstruation
  • Good option for women who cannot or prefer not to use hormonal methods 2

• NSAIDs (e.g., ibuprofen, mefenamic acid)

  • Modest reduction in bleeding (20-40%) 5
  • Example: ibuprofen 600-800 mg every 6-8 hours with food 1
  • Can be combined with hormonal methods for breakthrough bleeding 6

3. Other Treatment Options

• Iron supplementation

  • Should be considered if bleeding is heavy or prolonged to prevent anemia 1
  • Oral ferrous sulfate recommended if anemia develops

• GnRH agonists

  • For short-term use in specific situations
  • Effective but with significant side effects (bone loss, menopausal symptoms) 4

• Surgical options (when medical therapy fails)

  • Endometrial ablation
  • Myomectomy (for fibroids, if fertility preservation desired)
  • Hysterectomy (definitive treatment) 7

Management Algorithm for Breakthrough Bleeding on Hormonal Contraceptives

1. Rule out non-functional causes:

   • Pregnancy
   • Infection
   • Malignancy 3

2. Initial management:

   • Reassurance for first 3 months of use (bleeding commonly improves with time) 6
   • Ensure correct and consistent use of the method 3

3. If bleeding persists beyond 3 months:

   • Add supplemental estrogen and/or NSAIDs during bleeding episodes 6
   • For OCPs: Consider changing to a formulation with higher estrogen content or different progestin 6

Common Pitfalls and Caveats

• Missed periods on hormonal contraceptives:

  • If patient has adhered to prescribed regimen, pregnancy should be ruled out before continuing use 3
  • Amenorrhea is an expected side effect of LNG-IUS and not harmful 1

• Structural causes:

  • Transvaginal ultrasound alone may miss endometrial polyps and some fibroids
  • Sonohysterography or hysteroscopy may be needed for definitive diagnosis 5

• Underlying bleeding disorders:

  • Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 7
  • Consider hematologic evaluation in cases of severe or treatment-resistant bleeding

• Fertility concerns:

  • Hormonal contraceptive use does not increase the risk of future infertility 1
  • Counsel appropriately to address this common concern

By following this evidence-based approach, most cases of heavy vaginal bleeding can be effectively managed with medical therapy, reserving surgical interventions for those with significant pathology or who fail medical management.