What is the initial workup and management for a patient with excessive menstrual bleeding?

Initial Workup and Management of Excessive Menstrual Bleeding

The initial workup for excessive menstrual bleeding should include a complete blood count, pregnancy test, thyroid function tests, prolactin levels, and transvaginal ultrasound, followed by first-line medical management with either levonorgestrel-releasing intrauterine system (LNG-IUS), tranexamic acid, or combined hormonal contraceptives based on patient needs. 1

Diagnostic Approach

Initial Laboratory Assessment

• Pregnancy test (to rule out pregnancy-related bleeding)
• Complete blood count (to assess for anemia)
• Thyroid function tests (to rule out thyroid dysfunction)
• Prolactin levels (to assess for hyperprolactinemia)
• Blood typing and cross-matching (if severe bleeding is present) 1

Imaging and Additional Testing

• Transvaginal ultrasonography (first-line imaging to evaluate structural causes) 1
• Saline infusion sonohysterography (if polyps or submucosal fibroids are suspected) 1
• Endometrial biopsy (for women ≥35 years with recurrent anovulation or risk factors for endometrial hyperplasia/cancer) 1

Classification

• Use the PALM-COEIN classification system:
  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy/hyperplasia
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified 1

Management Algorithm

First-Line Medical Treatment Options

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

   • Most effective first-line treatment with 71-95% reduction in menstrual blood loss 1, 2
   • Provides contraception and long-term management
   • Consider as first option for women needing both treatment and contraception

2. Tranexamic acid

   • Reduces menstrual blood loss by 26-60% 3
   • Dosage: 3.9-4 g/day for 4-5 days starting from first day of menstrual cycle 3
   • Contraindicated in active thromboembolic disease or history/risk of thrombosis 1, 3
   • Good option for women who want to preserve fertility and only need treatment during menstruation

3. NSAIDs

   • Reduces menstrual blood loss by 20-60% 4
   • Use for 5-7 days during menstruation 5, 1
   • Less effective than tranexamic acid or LNG-IUS 2, 6
   • May increase cardiovascular risk with long-term use 1

4. Combined hormonal contraceptives

   • Effective for reducing menstrual blood loss 1
   • Can be used in extended or continuous regimens
   • Good option for women who also need contraception
   • Monitor blood pressure during follow-up 5

5. Oral progestins

   • Effective when given for 21 days per month 1
   • Less effective than LNG-IUS or combined hormonal contraceptives 1
   • Option when estrogen is contraindicated

Treatment Selection Based on Patient Factors

• For women needing contraception: LNG-IUS or combined hormonal contraceptives 1
• For women not needing contraception: Tranexamic acid, NSAIDs, or cyclic progestins 1
• For perimenopausal women: Cyclic progestin or cyclic estrogen with progestin 1
• For women with contraindications to hormonal therapy: Tranexamic acid or NSAIDs 1, 3

Second-Line Treatment Options

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

1. Endometrial ablation

   • Consider for women with completed childbearing 1
   • Less invasive alternative to hysterectomy
   • Preserves uterus with fewer complications than hysterectomy 1

2. Hysterectomy

   • Definitive treatment for refractory cases 1
   • Consider when other treatments have failed
   • Indicated when significant intracavitary lesions are present 1

Follow-up Recommendations

• Assess treatment effectiveness after 3 months
• If bleeding persists or is unacceptable to the patient, consider changing to another medical treatment or proceeding to second-line options 5
• No routine follow-up visit is required for most treatments, but advise patients to return if problems arise 5

Common Pitfalls and Caveats

• Don't rely solely on patient's subjective assessment of blood loss; objective measures are more reliable 4
• Don't forget to evaluate for underlying conditions before initiating symptomatic treatment 5, 1
• Cyclic progestogens are not significantly effective in women who ovulate normally 4
• Tranexamic acid is contraindicated in women with active thromboembolic disease or high risk of thrombosis 1, 3
• Always consider quality of life impact when selecting treatment options, not just reduction in blood volume 2