When should I be concerned about a patient presenting with prolonged menstrual bleeding?

When to Be Concerned About Prolonged Menstrual Bleeding

You should be concerned about prolonged menstrual bleeding when it saturates a large pad or tampon hourly for at least 4 hours, causes hemodynamic instability, or is associated with underlying pathology. 1

Definition and Initial Assessment

• Prolonged menstrual bleeding is defined as bleeding lasting more than 8 days or excessive menstrual blood loss (>80 mL per cycle) that interferes with a woman's physical, emotional, social wellbeing and quality of life 2
• Heavy or prolonged bleeding, whether scheduled or unscheduled, is uncommon during hormonal contraceptive use and warrants evaluation 3
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss requiring urgent evaluation 1

When to Be Concerned

Immediate Concerns (Requiring Urgent Evaluation)

• Bleeding that saturates a large pad or tampon hourly for at least 4 hours 1
• Signs of hemodynamic instability (tachycardia, hypotension) 1
• Severe anemia requiring blood transfusion 4
• Abrupt change from regular bleeding pattern to heavy bleeding 3

Underlying Conditions to Rule Out

• Pregnancy (including ectopic pregnancy) - test for pregnancy in all reproductive-age women with abnormal uterine bleeding 1, 3
• Underlying gynecological problems such as:
  • Interactions with medications 3
  • Sexually transmitted diseases 3
  • New pathologic uterine conditions (polyps, fibroids) 3, 5
  • Endometrial hyperplasia or neoplasia 5
  • Adenomyosis 5

Special Populations with Higher Risk

• Adolescents with heavy menstrual bleeding have a higher prevalence of bleeding disorders than the general population 4
• Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 2
• Women on anticoagulant therapy may experience worsened menstrual bleeding 1
• Women using factor Xa inhibitors have a 32% incidence of abnormal uterine bleeding 3

Evaluation Algorithm

1. Initial assessment:

   • Evaluate bleeding pattern and severity 3
   • Check for hemodynamic stability 1
   • Perform pregnancy test 3

2. If clinically indicated, evaluate for underlying conditions:

   • Gynecological examination 3
   • Laboratory tests to rule out anemia and bleeding disorders, especially if there's a pattern of heavy bleeding since menarche 4
   • Ultrasound scan to rule out structural abnormalities 2

3. Consider referral to specialist when:

   • Bleeding is unresponsive to first-line treatments 3
   • Severe anemia is present 4
   • Structural abnormalities are identified 2
   • Suspected bleeding disorder 4

Management Approach

If an underlying gynecologic problem is not found and treatment is desired, options include:

• NSAIDs for short-term treatment (5-7 days) 3
• Hormonal treatment (if medically eligible) with low-dose combined oral contraceptives or estrogen for short-term treatment (10-20 days) 3
• Antifibrinolytic medications such as tranexamic acid, which can reduce menstrual blood loss compared to placebo and NSAIDs 6
• Levonorgestrel-releasing intrauterine system (LNG-IUD), which reduces menstrual blood loss by 71-95% 1

Important Caveats

• Prolonged bleeding with hormonal contraceptives (implants, injections) is often not harmful but should be evaluated if persistent or concerning to the patient 3
• If irregular bleeding persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods 3
• Enhanced counseling about expected bleeding patterns with hormonal contraceptives can reduce discontinuation rates 3
• Women with abnormal uterine bleeding around perimenopause (age 40-50) have a higher prevalence of structural abnormalities and require thorough evaluation 5