What is the treatment for prolonged bleeding in a female?

Treatment for Prolonged Bleeding in Females

For prolonged bleeding in females, the first-line treatment depends on the underlying cause, but typically includes NSAIDs for 5-7 days during bleeding episodes, with hormonal treatments such as combined oral contraceptives or estrogen for 10-20 days as additional options when medically appropriate. 1

Initial Evaluation

Before initiating treatment, it's essential to determine if there's an underlying gynecological problem:

• Rule out pregnancy with an hCG test 2
• Consider potential underlying causes:
  • Interactions with medications 1
  • Sexually transmitted diseases 1
  • New pathologic uterine conditions (polyps, fibroids) 1
  • Coagulation disorders (particularly von Willebrand disease) 2, 3
  • Thyroid dysfunction 2
  • Endometrial hyperplasia or cancer 2

Treatment Algorithm Based on Contraceptive Method

For Women Not Using Hormonal Contraception

1. First-line treatment:

   • NSAIDs for 5-7 days during bleeding episodes 1
   • Options include mefenamic acid, indomethacin, and other NSAIDs 1, 4

2. Second-line treatment:

   • Tranexamic acid during days of bleeding 5, 6, 7
   • Levonorgestrel-releasing intrauterine system (LNG-IUS) for long-term management 6, 3
   • Combined hormonal contraceptives for 10-20 days (if medically eligible) 1, 6

For Cu-IUD Users

• NSAIDs for 5-7 days during bleeding episodes 1
• If bleeding persists and is unacceptable, consider alternative contraceptive methods 1

For LNG-IUD, Implant, or Injectable Users

• NSAIDs for 5-7 days during bleeding 1
• Hormonal treatment with combined oral contraceptives or estrogen for 10-20 days (if medically eligible) 1

Special Considerations

Tranexamic Acid

• FDA-approved for treatment of ovulatory bleeding 2
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1, 5
• Should not be used concurrently with hormonal contraceptives due to increased risk of thromboembolic events 5

Persistent Bleeding

If bleeding persists despite medical therapy:

• Consider endometrial biopsy for women ≥35 years with recurrent anovulation or <35 years with risk factors for endometrial cancer 2
• Evaluate for structural causes with transvaginal ultrasound or saline infusion sonohysterography 2
• Consider surgical options if medical management fails:
  • Polypectomy or fibroidectomy if structural causes identified 2
  • Endometrial ablation 2, 7
  • Hysterectomy as definitive treatment when other options fail 2, 7

Pitfalls and Caveats

• Heavy or prolonged bleeding may be a sign of serious underlying conditions and should not be dismissed without proper evaluation 1
• Aspirin has not shown significant benefit and may increase blood loss in some women 1
• Enhanced counseling about expected bleeding patterns with contraceptive methods can improve continuation rates 1
• Tranexamic acid is effective but should be used cautiously in women with risk factors for thrombosis 5
• Always consider the woman's fertility desires when selecting treatment options 3, 7