What medications can help slow heavy menstrual bleeding?

Medications for Heavy Menstrual Bleeding

NSAIDs and tranexamic acid are the most effective first-line medications for reducing heavy menstrual bleeding, with tranexamic acid showing superior efficacy in reducing blood loss by 26-60%. 1, 2

First-Line Treatment Options

NSAIDs

• NSAIDs like ibuprofen are effective for short-term treatment (5-7 days) of heavy menstrual bleeding 1
• They work by inhibiting prostaglandin synthesis, reducing uterine contractions and menstrual fluid prostaglandin levels 3
• NSAIDs have been shown to significantly reduce menstrual blood loss compared to placebo 1
• Standard dosing of ibuprofen (400mg three times daily) during days of bleeding can effectively reduce menstrual blood loss 3

Tranexamic Acid

• Tranexamic acid is a non-hormonal option that significantly reduces menstrual blood loss by 26-60%, making it more effective than NSAIDs 2, 4
• The recommended oral dosage is 3.9-4g/day for 4-5 days starting from the first day of the menstrual cycle 2
• Tranexamic acid works by inhibiting fibrinolysis, preventing fibrin degradation in the endometrium 4
• It significantly improves quality of life in women with heavy menstrual bleeding 5
• Important contraindication: tranexamic acid should not be used in women with active thromboembolic disease or history/risk of thrombosis 1, 2

Hormonal Options

Combined Oral Contraceptives

• Estrogen-progestin oral contraceptive pills effectively reduce bleeding symptoms and are considered first-line therapy 6, 7
• They provide the additional benefit of contraception while managing heavy bleeding 7

Progestin-Containing IUDs

• Levonorgestrel-releasing intrauterine devices (LNG-IUDs) are highly effective at reducing menstrual blood loss 1, 7
• Over time, bleeding generally decreases with LNG-IUD use, with many women experiencing only light menstrual bleeding or amenorrhea 1
• LNG-IUDs have been shown to reduce blood loss more effectively than tranexamic acid (96% reduction after 12 months) 4

Second-Line Treatment Options

GnRH Agonists and Antagonists

• For persistent heavy bleeding, GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) can be considered 1, 7
• These medications reduce bleeding symptoms and significantly decrease fibroid volume by 18-30% 7
• Side effects include hypoestrogenic effects (headaches, hot flushes, bone mineral density loss) 1
• Combination treatment with low doses of estrogen and progestin can mitigate these side effects 1

Treatment Algorithm for Heavy Menstrual Bleeding

1. Initial Assessment: Rule out underlying gynecological problems (e.g., fibroids, polyps, IUD displacement) 1

2. First-Line Treatment:

   • For immediate relief: Tranexamic acid 3.9-4g/day for 4-5 days starting on first day of menses 2, 5
   • Alternative: NSAIDs (e.g., ibuprofen 400mg three times daily) during days of bleeding 1, 3
   • For long-term management: Consider hormonal options like combined oral contraceptives or LNG-IUD 6, 7

3. If First-Line Treatment Fails:

   • Consider switching between tranexamic acid and NSAIDs or using them in combination 8
   • Consider hormonal options if not already tried 7
   • For persistent symptoms, consider second-line options like GnRH modulators 1, 7

4. If Medical Management Fails:

   • Consider surgical options or referral to specialist care 1

Important Considerations and Caveats

• Tranexamic acid has few adverse effects, mainly mild gastrointestinal symptoms 2, 4
• NSAIDs may cause gastric irritation, though ibuprofen shows less gastric irritation than aspirin 3
• For women with copper IUDs experiencing heavy bleeding, NSAIDs are particularly helpful 1
• Combination of treatments may be more effective than single agents for some women 8
• If bleeding persists despite treatment and is unacceptable to the patient, consider alternative contraceptive methods or referral for further evaluation 1