How to manage heavy menstrual bleeding?

Management of Heavy Menstrual Bleeding

For women with heavy menstrual bleeding, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment, reducing menstrual blood loss by 71-95% while addressing the underlying cause of bleeding. 1

Initial Assessment

• Evaluate severity of bleeding - bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation 1
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss 1
• Rule out underlying gynecological problems such as IUD displacement, STDs, pregnancy, or pathologic uterine conditions (polyps, fibroids) 2

First-Line Treatment Options

1. Levonorgestrel-releasing IUD (LNG-IUD)

• Most effective first-line treatment, reducing menstrual blood loss by 71-95% 1, 3
• Over time, bleeding generally decreases, and many women experience only light menstrual bleeding or amenorrhea 2
• Best option for women not seeking immediate pregnancy 3

2. Combined Hormonal Contraceptives

• Second choice after LNG-IUD for women not seeking pregnancy 3
• Available as oral pills or vaginal rings 3

3. Antifibrinolytics (Tranexamic Acid)

• Reduces menstrual blood loss by 26-60% 4
• Recommended oral dosage: 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 4
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2

4. NSAIDs

• Short-term treatment (5-7 days during bleeding) 2
• Less effective than tranexamic acid but more effective than placebo 5
• Options include indomethacin, mefenamic acid, flufenamic acid, and diclofenac sodium 2
• Most studies demonstrate statistically significant reductions in menstrual blood loss 2

5. Progestogens

• Long-cycle oral progestogens (≥3 weeks per cycle) reduce menstrual blood loss 6
• Short-course oral progestogens (≤14 days per cycle) are less effective but may be sufficient for marginally increased blood loss 3

Treatment Algorithm

1. For women not seeking pregnancy:

   • First choice: LNG-IUD 1, 3
   • Second choice: Combined hormonal contraceptives 3

2. For women seeking pregnancy or with contraindications to hormonal methods:

   • First choice: Tranexamic acid 4, 6
   • Second choice: NSAIDs 5

3. If first-line treatments fail:

   • Consider second-line treatments including endometrial ablation techniques 1
   • Hysterectomy should be considered only after less invasive procedures have been attempted 1

Management Based on Contraceptive Method

For Cu-IUD users with heavy bleeding:

• NSAIDs for 5-7 days during bleeding 2
• If bleeding persists and is unacceptable, consider alternative contraceptive methods 2

For LNG-IUD users with persistent heavy bleeding:

• NSAIDs for 5-7 days 2
• Hormonal treatment with COCs or estrogen (10-20 days) if medically eligible 2

For injectable contraceptive users:

• Consider a hormone-free interval of 3-4 consecutive days for heavy bleeding 2
• NSAIDs for 5-7 days 2
• Hormonal treatment with COCs or estrogen (10-20 days) if medically eligible 2

Common Pitfalls and Caveats

• Failure to rule out underlying gynecological conditions before initiating treatment 2
• Inadequate counseling about expected bleeding patterns, which can lead to treatment discontinuation 2
• Prescribing tranexamic acid to women with thromboembolic disease or risk factors 4
• Using aspirin for treatment, which may increase blood loss in women with normal or low baseline menstrual blood loss 2
• Expecting immediate results with medical therapy - most treatments take 1-3 months to show maximum benefit 3

Remember that unscheduled spotting or light bleeding, as well as heavy or prolonged bleeding, is common during the first 3-6 months of contraceptive use and generally decreases with continued use 2.