What is the initial treatment approach for a patient presenting to the Emergency Room (ER) with menorrhagia lasting over 12 weeks?

Emergency Room Treatment for Menorrhagia Lasting Over 12 Weeks

The initial treatment for a patient presenting to the Emergency Room with menorrhagia lasting over 12 weeks should include tranexamic acid, intravenous fluid replacement, blood transfusion if necessary, and correction of coagulopathy. 1, 2

Initial Assessment and Management

• Assess the extent of bleeding using vital signs, mental status, and clinical presentation to determine severity 3
• Obtain baseline laboratory studies including complete blood count, coagulation profile (PT, aPTT), and fibrinogen levels 3
• Secure large-bore intravenous access to allow for rapid fluid resuscitation 3
• Administer intravenous fluid replacement with crystalloids for volume resuscitation 1, 3
• Consider blood transfusion if hemoglobin is below 7 g/dL, with a target hemoglobin of 7-9 g/dL 1, 3

Pharmacological Management

• Administer tranexamic acid (antifibrinolytic agent) as first-line treatment for acute menorrhagia in the ER setting 1, 2, 4
  • Typical dosing: 10-15 mg/kg followed by infusion of 1-5 mg/kg/h 5
  • Oral option: 1000-1500 mg three times daily if IV form not available 4
• Consider NSAIDs such as mefenamic acid to reduce blood loss through prostaglandin inhibition 2, 6, 7
• For patients with severe thrombocytopenia, progestins may be useful in treating menorrhagia, but DMPA (depot medroxyprogesterone acetate) should be used with caution due to increased or erratic bleeding on initiation 1

Correction of Coagulopathy

• Correct any underlying coagulopathy that may be contributing to the bleeding 3
• Maintain fibrinogen levels above 120 mg/dL in patients with active bleeding 1
• Avoid overuse of blood products in patients without clear indications, as this carries significant risks 1

Further Management Considerations

• For hemodynamically unstable patients with persistent heavy bleeding despite medical management, consider gynecological consultation for possible surgical intervention 4, 8
• If the patient is stabilized in the ER, arrange follow-up with gynecology for consideration of longer-term management options 4, 8:
  • Levonorgestrel-releasing intrauterine device (most effective medical therapy) 2, 4, 7
  • Oral contraceptives containing estrogen and progestin 6, 4
  • Continuous progestin therapy 8
  • Endometrial ablation or hysterectomy for refractory cases 4, 8

Common Pitfalls and Considerations

• Do not rely solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 3
• Recognize that menorrhagia may be a symptom of underlying conditions requiring specific treatment (e.g., thyroid disorders, coagulation disorders, endometrial pathology) 6, 4
• Avoid delays in administering tranexamic acid, as early administration is associated with better outcomes 5, 3
• For patients with severe anemia, consider iron supplementation in addition to other treatments 4