What are the treatment options for prolonged menstrual bleeding?

Treatment Options for Prolonged Menstrual Bleeding

Combined hormonal contraceptives are the first-line treatment option for prolonged menstrual bleeding, with levonorgestrel intrauterine systems (LNG-IUD) being equally effective for women with abnormal uterine bleeding. 1

Initial Assessment and Classification

When evaluating prolonged menstrual bleeding, consider:

• Classification using the PALM-COEIN system:

  • Structural causes (PALM): Polyps, Adenomyosis, Leiomyomas (fibroids), Malignancy
  • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 1

• Transvaginal and transabdominal ultrasound with Doppler is the most appropriate initial imaging study 1

• Consider underlying conditions like thyroid dysfunction, coagulation disorders (especially von Willebrand disease), PCOS, or medication effects 2

First-Line Medical Treatment Options

1. Combined Hormonal Contraceptives (CHCs)

   • Recommended as first-line for many patients with abnormal uterine bleeding 1
   • Benefits: cycle regulation, decreased bleeding, reduced cramping
   • Start with a monophasic pill containing 30-35 μg ethinyl estradiol with a progestin such as levonorgestrel or norgestimate 1
   • Can be used in continuous regimens to reduce or eliminate menstrual bleeding 1
   • Typical failure rate: 5-9% 1

2. Levonorgestrel Intrauterine System (LNG-IUD)

   • Highly effective for menorrhagia, comparable to endometrial ablation or hysterectomy 3
   • Approximately 50% of users experience amenorrhea or oligomenorrhea by 2 years 1
   • Typical failure rate: 0.1-0.2% 1
   • Note: Spotting or light bleeding is common during first 3-6 months but typically decreases 1

3. Tranexamic Acid

   • Reduces menstrual blood loss by 20-60% 3
   • Specifically approved by FDA for ovulatory bleeding 2
   • Take during heavy bleeding days

4. NSAIDs (e.g., Ibuprofen)

   • Recommended dose: 600-800 mg every 6-8 hours with food for first 24-48 hours of symptoms 1
   • Reduces menstrual blood loss by 20-60% 3
   • Avoid in patients with bleeding disorders 4

Second-Line Options

1. Progestin-Only Methods

   • Oral progesterone for 21 days per month can be effective for menorrhagia 2
   • For persistent irregular bleeding on continuous hormonal methods, interrupt use for 3-4 consecutive days to induce bleeding (no more than once a month) 1
   • Cyclic progestogens are not significantly effective in women who ovulate normally 3

2. Injectable Contraception (DMPA)

   • Typical failure rate: 0.3-6% 1
   • Can lead to amenorrhea with continued use

3. Progesterone Capsules

   • For secondary amenorrhea: 300-400 mg daily for 10 days can induce withdrawal bleeding in 74-77% of women 5
   • Common side effects include headache, dizziness, abdominal pain, and breast tenderness 5

Surgical Options (When Medical Management Fails)

Consider surgical intervention when:

• Medical treatment fails
• Contraindication or intolerance to medical treatment
• Significant intracavitary lesions 1

Options include:

1. Endometrial ablation
2. Polypectomy or fibroidectomy for structural causes
3. Uterine artery embolization for fibroids
4. Hysterectomy (most definitive treatment) 2

Special Considerations

• Anemia: Iron supplementation is crucial for patients with iron-deficiency anemia due to prolonged bleeding 4

• Bleeding Disorders: Women with inherited bleeding disorders (von Willebrand disease, platelet disorders) often experience menorrhagia 4

  • Desmopressin may be used in responsive patients
  • Avoid NSAIDs

• Adolescents: Low-dose combined oral contraceptives (≤35 μg ethinyl estradiol) are first-line for regulating cycles 1

  • Continuous regimens can be particularly helpful
  • LNG-IUD and certain hormonal methods may be avoided in this population 4

Non-Pharmacological Approaches

• Applying heat to the lower abdomen or back can reduce cramping pain 1
• Acupressure at specific points (LI4 and SP6) may help reduce cramping 1

Follow-Up

• Assess response to treatment after 3 months 1
• Regular follow-up to address persistent adverse effects or adherence issues
• If bleeding pattern doesn't improve with first-line therapy, consider alternative options or further investigation