What is the best course of action for prolonged menstrual bleeding lasting a month?

Management of Prolonged Menstrual Bleeding

For prolonged menstrual bleeding lasting a month, the most effective first-line medical management options include hormonal contraceptives (particularly the levonorgestrel-releasing intrauterine system), tranexamic acid, and NSAIDs as recommended by clinical guidelines. 1

Diagnostic Considerations

When evaluating prolonged menstrual bleeding (lasting one month), consider:

• Definition: Heavy menstrual bleeding (HMB) is defined as blood loss >80 mL per cycle that interferes with physical, emotional, and social wellbeing 2
• Underlying causes:
  • Uterine pathologies (fibroids, polyps)
  • Coagulopathy (up to 20% of women with HMB have an underlying inherited bleeding disorder) 2
  • Ovulation dysfunction
  • Iatrogenic causes

Treatment Algorithm

First-Line Options

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

   • Most effective medical treatment for HMB 1, 3
   • Excellent option for women with fibroids, anemia, severe dysmenorrhea 1
   • Reduces menstrual blood loss more effectively than combined oral contraceptives 3
   • 50% of users experience amenorrhea or oligomenorrhea by 2 years 1

2. Tranexamic acid

   • Antifibrinolytic that reduces bleeding by inhibiting clot-dissolving enzymes 4
   • Moderate-quality evidence shows it reduces menstrual blood loss compared to placebo 4
   • Take during menstrual period only
   • More effective than NSAIDs for reducing blood loss 4

3. NSAIDs (e.g., ibuprofen 600-800 mg every 6-8 hours)

   • Recommended for first 24-48 hours of symptoms 1
   • Reduces prostaglandin levels which are elevated in women with HMB 5
   • Less effective than tranexamic acid but better than placebo 5
   • Can be used in combination with hormonal treatments 2

Second-Line Options

1. Combined hormonal contraceptives

   • Moderate-quality evidence shows they reduce HMB compared to placebo 3
   • If using COCs, consider those containing norgestimate (30-35 μg ethinyl estradiol) or levonorgestrel (30-40 μg ethinyl estradiol) 1
   • Typical failure rate for contraception: 5-9% 1

2. Progestin-only methods

   • Consider for patients with risk factors for thrombosis 1
   • Options include progestin-only pills or injectable contraception (DMPA)

Special Considerations

When to Consider Further Evaluation

• Endometrial biopsy: Highly sensitive (99.6%) for detecting endometrial carcinoma in patients with risk factors for endometrial pathology 1
• Transvaginal ultrasonography: Useful for evaluating structural abnormalities 1
• Bleeding disorders: Consider screening if heavy bleeding started at menarche or if there's a family history of bleeding disorders 2

Warning Signs Requiring Urgent Evaluation

• Severe anemia
• Significant clotting
• Irregular bleeding patterns (73% of women who consult primary care with increased vaginal bleeding have at least one symptom of irregular bleeding) 6

Comparative Effectiveness

• LNG-IUS vs. COCP: LNG-IUS is more effective than COCP in reducing menstrual blood loss (OR 0.21,95% CI 0.09 to 0.48) 3
• Tranexamic acid vs. NSAIDs: Tranexamic acid is more effective (MD -73.00 mL per cycle, 95% CI -123.35 to -22.65) 4
• Tranexamic acid vs. progestogens: Tranexamic acid shows higher likelihood of improvement (RR 1.54,95% CI 1.31 to 1.80) 4

Common Pitfalls

• Assuming regular cycles: Many women with heavy menstrual bleeding also have irregular bleeding patterns 6
• Overlooking bleeding disorders: Up to 20% of women with HMB have underlying inherited bleeding disorders 2
• Delaying effective treatment: Prolonged heavy bleeding can lead to iron deficiency anemia and significantly impact quality of life
• Focusing only on bleeding control: Also address associated symptoms like pain and cramping

If medical management fails after 3 months, consider surgical options like endometrial ablation or, as a last resort, hysterectomy, which is the definitive treatment but most invasive option 1, 2.