What are the next steps in managing this patient's heavy menstrual bleeding?

Management of Heavy Menstrual Bleeding

The next step in managing this patient's heavy menstrual bleeding should be initiating a levonorgestrel-releasing intrauterine system (LNG-IUS), which provides a 71-95% reduction in menstrual blood loss and is recommended as first-line treatment by multiple guidelines. 1

Diagnostic Evaluation Before Treatment

Before initiating treatment, ensure:

• Pregnancy test is negative
• Complete blood count to assess for anemia
• Thyroid function tests and prolactin levels
• Transvaginal ultrasound to evaluate for structural causes
  • Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study 2
  • If uterus is incompletely visualized, MRI without and with contrast is the next appropriate imaging study 2

Treatment Algorithm

First-Line Treatment:

• Levonorgestrel-releasing intrauterine system (LNG-IUS)
  • Most effective medical treatment with 71-95% reduction in menstrual blood loss 1
  • Mirena (20 μg/day) has the strongest evidence for efficacy 1

Alternative First-Line Options (if LNG-IUS is contraindicated or declined):

1. Tranexamic acid

   • 26-60% reduction in menstrual blood loss 1
   • Take only during menstruation
   • Contraindication: Active thromboembolic disease or history/risk of thrombosis 1, 3

2. Combined hormonal contraceptives

   • Can be used in extended or continuous regimens
   • Effective for reducing menstrual blood loss 1

3. NSAIDs (e.g., ibuprofen)

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

4. Long-course oral progestins

   • Option when estrogen is contraindicated
   • Oral progestins for 21 days per month are effective 1

Special Considerations

For Patients with Bleeding Disorders:

• Up to 20% of women with heavy menstrual bleeding may have an inherited bleeding disorder 1, 5
• Consider hematological investigations if bleeding score is high
• Tranexamic acid is particularly useful in these cases 5
• Avoid NSAIDs in patients with bleeding disorders 5

For Patients with Cardiovascular Risk:

• Avoid NSAIDs and tranexamic acid due to increased risk of thrombosis 1
• LNG-IUS is preferred over systemic hormones for women on antiplatelet therapy 1

Treatment Failure Management

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

1. Endometrial ablation

   • For women with completed childbearing
   • Less invasive alternative to hysterectomy
   • Second-generation techniques include thermal balloon, microwave, radiofrequency 1, 6

2. Hysterectomy

   • Definitive treatment for refractory cases
   • Should not be first-line treatment 1, 6
   • If performed, vaginal or laparoscopic routes are preferred 6

Monitoring Response to Treatment

• Reassess bleeding pattern after 3 months of treatment
• Monitor hemoglobin levels if anemia was present at baseline
• For patients on long-term treatment (>3 months), consider ophthalmic monitoring including visual acuity 3

Common Pitfalls to Avoid

1. Failing to rule out structural causes before initiating medical therapy
2. Using tranexamic acid in patients with history of thrombosis
3. Prolonged use of NSAIDs without considering cardiovascular risks
4. Delaying definitive treatment in cases of treatment failure
5. Not considering the possibility of inherited bleeding disorders in persistent cases

By following this algorithm, you can effectively manage heavy menstrual bleeding while minimizing risks and optimizing quality of life for your patient.