What are the initial management options for heavy menstrual bleeding?

Initial Workup and Management of Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the first-line treatment for heavy menstrual bleeding, providing 71-95% reduction in menstrual blood loss. 1

Diagnostic Evaluation

Initial Assessment

• Perform pregnancy test (to rule out pregnancy-related bleeding)
• Order thyroid function tests and prolactin levels
• Consider endometrial biopsy for women ≥35 years with recurrent anovulation or risk factors
• Obtain transvaginal ultrasonography or saline infusion sonohysterography to evaluate for structural causes

Classification Using PALM-COEIN System

• Structural causes (PALM): Polyps, Adenomyosis, Leiomyomas (fibroids), Malignancy
• Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise specified

Management Algorithm

First-Line Treatment Options

1. Levonorgestrel-releasing intrauterine system (LNG-IUS)

   • Most effective medical treatment with 71-95% reduction in menstrual blood loss 1, 2
   • Mirena (20 μg/day) has the strongest evidence for efficacy 1
   • Provides contraception and treats heavy bleeding simultaneously

2. Combined hormonal contraceptives

   • Oral or vaginal ring options
   • Second-best medical option when LNG-IUS is not suitable 2
   • Can be used in extended or continuous regimens for better bleeding control

3. Tranexamic acid

   • Reduces menstrual blood loss by 26-60% 3
   • Take only during menstruation (3.9-4 g/day for 4-5 days) 3
   • Caution: Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

4. NSAIDs

   • Short-term use (5-7 days) during menstruation 4, 1
   • Modest reduction in blood loss 5
   • Recommended dose: 400-800 mg every 4-6 hours as needed 1
   • Less effective than tranexamic acid or hormonal methods 6

Second-Line Treatment Options

1. Long-course oral progestins
   • Less effective than LNG-IUS or combined hormonal contraceptives 2
   • Useful when estrogen is contraindicated
   • Oral progestins for 21 days per month can be effective 1

Treatment Failure and Surgical Options

If medical management fails after 3-6 months of adequate trial:

1. Endometrial ablation

   • For women with completed childbearing
   • Less invasive alternative to hysterectomy
   • Potential complications include delayed diagnosis of endometrial cancer, post-ablation syndrome, uterine perforation, fluid overload, infection, and bleeding 1

2. Hysterectomy

   • Definitive treatment for refractory cases 1
   • Most effective for permanent resolution of heavy menstrual bleeding 6
   • Consider minimally invasive approaches (vaginal or laparoscopic) when possible

Special Considerations

For Women with Abnormal Uterine Bleeding on Antiplatelet Therapy

• Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate 4
• LNG-IUS is preferred over systemic hormones 4, 1
• Avoid NSAIDs and tranexamic acid due to increased risk of thrombosis 4, 1

For Women with Uterine Fibroids

• LNG-IUS can be effective for reducing bleeding in women with fibroids 4
• Consider hysteroscopic myomectomy for pedunculated submucosal fibroids <5 cm 4
• Medical options include NSAIDs, combined hormonal contraceptives, and tranexamic acid 4

Monitoring and Follow-up

• Reassess after 3 months of treatment to evaluate effectiveness
• If bleeding persists and remains unacceptable despite treatment, consider alternative methods or referral for surgical management
• For Cu-IUD users with heavy bleeding, NSAIDs can be used for short-term treatment (5-7 days) 4

The management of heavy menstrual bleeding should follow a stepwise approach, starting with the most effective and least invasive options. LNG-IUS has emerged as the superior first-line treatment based on the most recent evidence, with combined hormonal contraceptives and tranexamic acid as reasonable alternatives when LNG-IUS is not suitable or desired.