What is the management plan for individuals experiencing blood clots during their menstrual period?

Management of Blood Clots During Menstrual Period

The management of blood clots during menstruation should focus on identifying the underlying cause and implementing appropriate treatment, with NSAIDs being first-line therapy for most cases of heavy menstrual bleeding with clots. 1

Assessment of Blood Clots During Menstruation

• Blood clots during menstruation are often associated with heavy menstrual bleeding (HMB), which can be defined as excessive menstrual blood loss that interferes with a woman's physical, emotional, and social wellbeing 2
• Initial assessment should determine whether the bleeding is related to:
  • Structural causes (polyp, adenomyosis, leiomyoma, malignancy) 1
  • Ovulatory dysfunction 1
  • Coagulopathy or bleeding disorder 1
  • Iatrogenic causes (e.g., anticoagulation therapy) 3

Severity Assessment

• Blood clots ≥1 inch in diameter, "flooding" (changing pad/tampon more than hourly), and low ferritin levels are predictive of significant heavy menstrual bleeding 4
• Determine if bleeding meets criteria for major bleeding:
  • Hemodynamic instability
  • Clinically overt bleeding with hemoglobin decrease ≥2 g/dL
  • Requirement for ≥2 units of red blood cells 1

Management Algorithm

First-Line Treatment Options

• For most women with blood clots during menstruation without severe bleeding:
  • NSAIDs (5-7 days of treatment) - reduces menstrual blood loss and may help with clots 1
  • If NSAIDs are ineffective or contraindicated, consider hormonal therapy:
    • Combined hormonal contraceptives (if medically eligible) 1
    • Progestin-only contraception 1

For Women Using Contraceptives Who Experience Blood Clots

• For copper IUD users with heavy bleeding or clots:
  • NSAIDs for 5-7 days of treatment 1
• For hormonal IUD users with breakthrough bleeding or clots:
  • NSAIDs for 5-7 days of treatment
  • Additional hormonal treatment with combined oral contraceptives if medically eligible 1
• For implant or injectable contraceptive users with heavy bleeding:
  • NSAIDs for 5-7 days of treatment
  • Consider hormonal treatment with combined oral contraceptives if medically eligible 1

For Women with Suspected Bleeding Disorders

• If blood clots are accompanied by a personal or family history of bleeding, refer to a hematologist 4
• Tranexamic acid may be particularly effective for women with underlying bleeding disorders 5
• For women with confirmed bleeding disorders, specific treatments may include:
  • Tranexamic acid
  • DDAVP (1-deamino-8-D-arginine) for certain inherited bleeding disorders
  • Factor concentrate administration for severe bleeding disorders 2

For Women with Severe Anemia from Heavy Menstrual Bleeding

• Urgent intervention is required for hemoglobin <5 g/dL 6
• Blood transfusion may be necessary for hemodynamic instability 6
• Implement definitive treatment to prevent recurrence once stabilized 6

Treatment Efficacy

• Antifibrinolytics (tranexamic acid):
  • Reduce mean blood loss by approximately 53 mL per cycle compared to placebo 5
  • More effective than NSAIDs in reducing blood loss (73 mL per cycle difference) 5
• Levonorgestrel intrauterine system (LNG-IUS):
  • More effective than tranexamic acid for heavy menstrual bleeding 5
• Combined hormonal contraceptives:
  • Effective for ovulatory dysfunction-related heavy bleeding 1

When to Consider Surgical Options

• If medical treatment fails or is contraindicated 1
• If the patient has significant intracavitary lesions 1
• Options include:
  • Endometrial ablation (for women who have completed childbearing) 2
  • Hysterectomy (definitive treatment when other options have failed) 2

Special Considerations

• For women on anticoagulation therapy experiencing blood clots during menstruation:
  • Consider modification of anticoagulation regimen if possible 3
  • Hormonal therapy may be used if the patient is adequately anticoagulated 3
• For women with risk factors for thrombosis:
  • Avoid estrogen-containing contraceptives 1
  • Consider progestin-only options or non-hormonal treatments 1

Follow-up Recommendations

• Advise women to return if bleeding persists or worsens 1
• Monitor for signs of severe anemia (fatigue, shortness of breath, dizziness) 6
• If bleeding disorder persists or woman finds treatment unacceptable, counsel on alternative methods 1