What medications are used to treat chronic vaginal bleeding?

Treatment of Chronic Vaginal Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment for chronic vaginal bleeding, with efficacy >99% and the added benefit of reducing menstrual blood loss. 1

First-Line Treatment Options

Levonorgestrel-releasing Intrauterine Device (LNG-IUD)

• Highly effective with typical failure rate of only 0.1-0.2% 1
• Significantly reduces menstrual bleeding volume 1, 2
• No increased risk of thrombosis 1
• Particularly beneficial for women with bleeding disorders 1
• More effective than combined oral contraceptives for reducing menstrual blood loss (OR 0.21,95% CI 0.09 to 0.48) 3

Tranexamic Acid

• Effective for acute and chronic heavy menstrual bleeding 2, 4
• Can be used in combination with hormonal methods to enhance effectiveness 1, 5
• Particularly useful for women with inherited bleeding disorders 4
• Can provide immediate improvement while waiting for hormonal treatments to take effect

Second-Line Treatment Options

Progestin-Only Methods

1. Progestin-Only Pills

   • Efficacy of 91-95% with typical use 1
   • No increased thrombosis risk (RR 0.90) 1
   • Drospirenone-containing progestin-only pills may be more effective than norethindrone for reducing bleeding 6

2. Depot Medroxyprogesterone Acetate (DMPA)

   • Efficacy of 94-97% (typical failure rate 0.3-6%) 1
   • May reduce bleeding over time 1
   • Caution: Associated with higher risk of venous thromboembolism compared to other progestin-only methods (RR 2.67) 1

3. Contraceptive Implant

   • Very high efficacy (failure rate 0.05%) 1
   • May cause irregular bleeding initially 6
   • NSAIDs or tranexamic acid can help manage breakthrough bleeding 6, 5

Combined Hormonal Contraceptives

• Effective for treating heavy menstrual bleeding in hemodynamically stable patients 2, 3
• Options include:
  • Oral contraceptives (failure rate 5-9%) 1
  • Contraceptive vaginal ring 3
  • Consider increasing estrogen content from 20 mcg to 35 mcg for better bleeding control 6
  • Decreasing hormone-free interval from seven to four days can improve bleeding patterns 6
• Caution: Avoid in women with risk factors for thrombosis 1

Management Algorithm for Chronic Vaginal Bleeding

1. Rule out structural causes (polyps, fibroids, malignancy) with appropriate imaging 2

   • Transvaginal ultrasound is the preferred imaging modality 2
   • Consider endometrial sampling in women ≥45 years or with risk factors 2

2. For hemodynamically stable patients with chronic bleeding:

   • First choice: LNG-IUD 1, 2, 3
   • Alternative options if LNG-IUD not suitable:
     • Oral progestins (continuous regimen) 2, 4
     • Combined hormonal contraceptives 3
     • Tranexamic acid 2, 4

3. For acute heavy bleeding episodes:

   • High-dose estrogen-progestin oral contraceptives 2, 4
   • Oral progestins 2, 4
   • Intravenous tranexamic acid 2, 4
   • NSAIDs as adjunctive therapy 1, 6

4. For patients with bleeding disorders:

   • LNG-IUD is strongly preferred 1
   • Tranexamic acid is particularly effective 4
   • All hormonal methods can be considered 4

Special Considerations

• Women with Von Willebrand disease: LNG-IUD is preferred over DMPA due to better safety profile 1
• Women with thrombosis risk: Avoid estrogen-containing contraceptives; use progestin-only methods 1
• Persistent bleeding despite treatment: Consider adding tranexamic acid to hormonal contraception 1
• Breakthrough bleeding on hormonal methods: Consider NSAIDs, tranexamic acid, or doxycycline 6, 5

Common Pitfalls to Avoid

1. Failing to rule out structural causes before initiating medical management
2. Using combined hormonal contraceptives in women with thrombosis risk factors
3. Not providing adequate counseling about expected bleeding patterns with different treatments
4. Discontinuing treatment too early before therapeutic effect is achieved
5. Not addressing breakthrough bleeding which can lead to treatment discontinuation

The choice of treatment should prioritize the LNG-IUD due to its superior efficacy in reducing menstrual blood loss while providing excellent contraception. For women who cannot use the LNG-IUD, a stepwise approach using other progestin-only methods or tranexamic acid is recommended.