What is the initial management for a 19-year-old female (19F) with heavy menstrual bleeding?

Initial Management of Heavy Menstrual Bleeding in a 19-Year-Old Female

For a 19-year-old female with heavy menstrual bleeding, first-line treatment should be nonsteroidal anti-inflammatory drugs (NSAIDs) for a short-term course of 5-7 days during days 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 2
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss 2, 3
• Rule out pregnancy in all reproductive-age women with abnormal uterine bleeding 2, 3
• If clinically indicated, evaluate for underlying gynecological problems, such as:
  • Sexually transmitted diseases
  • New pathologic uterine conditions (e.g., polyps or fibroids)
  • Medication interactions 1

First-Line Treatment Options

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 1
  • Multiple studies have demonstrated statistically significant reductions in mean total menstrual blood loss with NSAID use 1
  • Various NSAIDs have been studied, including indomethacin, mefenamic acid, flufenamic acid, and diclofenac sodium 1
  • There is no evidence of a difference between individual NSAIDs (naproxen and mefenamic acid) in reducing heavy menstrual bleeding 4, 5

Second-Line Treatment Options

• If bleeding persists and the woman finds it unacceptable after NSAID treatment:
  • Consider hormonal contraceptives:
    • Levonorgestrel-releasing intrauterine device (LNG-IUD) reduces menstrual blood loss by 71-95% 2, 6
    • Combined oral contraceptive pills are effective first-line treatments for heavy menstrual bleeding 1, 7
    • Cyclic oral progestin treatment can reduce bleeding by approximately 87% 2
  • Consider tranexamic acid:
    • One study among Cu-IUD users with heavy bleeding showed significant reduction in mean blood loss compared with placebo 1
    • Tranexamic acid is a non-hormonal alternative that may reduce bleeding symptoms 1, 7
    • Caution: Tranexamic acid is contraindicated in women with active thromboembolic disease or with a history or intrinsic risk for thrombosis 1

Special Considerations

• Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 6
• If an underlying gynecological problem is found, treat the condition or refer for care 1
• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful can improve treatment adherence 1
• If bleeding persists despite treatment and remains unacceptable, counsel on alternative contraceptive methods or refer for further management 1

Treatment Algorithm

1. Start with NSAIDs for 5-7 days during days of bleeding 1
2. If bleeding persists after 1-3 cycles of NSAID treatment, consider:
   • Hormonal options (LNG-IUD, combined oral contraceptives) 1, 2
   • Tranexamic acid (if no contraindications) 1, 7
3. If bleeding remains unacceptable despite medical treatment:
   • Counsel on alternative contraceptive methods 1
   • Consider referral for further evaluation and possible surgical management 6

Common Pitfalls

• Failing to rule out pregnancy or underlying gynecological conditions before initiating treatment 2, 3
• Not providing adequate counseling about expected bleeding patterns, which can lead to treatment discontinuation 1
• Using tranexamic acid in women with active thromboembolic disease or history of thrombosis 1
• Not considering the possibility of an underlying bleeding disorder in women with persistent heavy menstrual bleeding 6