What can be prescribed for a patient with irregular and heavy menstrual bleeding?

Treatment Options for Irregular and Heavy Menstrual Bleeding

For patients with irregular and heavy menstrual bleeding, combined oral contraceptives (COCs) containing 30-35 μg of ethinyl estradiol should be prescribed as first-line treatment, as they effectively reduce menstrual blood loss while providing hormonal regulation. 1, 2

First-Line Treatment Options

• Monophasic combined oral contraceptives (COCs) containing 30-35 μg of ethinyl estradiol are recommended as initial therapy for heavy menstrual bleeding, as they decrease blood loss by inducing regular shedding of a thinner endometrium 1, 2
• Extended or continuous cycle regimens of COCs may be beneficial for patients with severe menstrual bleeding to minimize blood loss 1
• The levonorgestrel-releasing intrauterine system (LNG-IUD) is an excellent alternative first-line option, especially for patients with cardiovascular risk factors or contraindications to COCs 1

Second-Line Treatment Options

• Tranexamic acid (3.9-4 g per day during menstruation) has been shown to be as effective as COCs in reducing menstrual blood loss 3
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days during menstruation can help reduce heavy bleeding 4
• Depot Medroxyprogesterone Acetate (DMPA) can suppress circulating androgen levels and pituitary gonadotropin levels, making it a viable second-line option 1

Management Algorithm for Heavy Menstrual Bleeding

1. Assess for underlying conditions: Before initiating treatment, evaluate for underlying conditions that may cause heavy bleeding 4

2. First-line treatment selection:

   • For patients without cardiovascular risk factors: Prescribe monophasic COCs with 30-35 μg ethinyl estradiol 1, 2
   • For patients with cardiovascular risk factors: Consider LNG-IUD 1

3. If first-line treatment fails or is contraindicated:

   • Try NSAIDs for 5-7 days during menstruation 4
   • Consider tranexamic acid during menstruation 3, 5
   • Consider DMPA as an injectable option 1, 6

4. For persistent bleeding despite treatment:

   • For COC users: Consider a hormone-free interval of 3-4 days (but not during first 21 days of use and not more than once per month) 4, 2
   • For DMPA users: Consider NSAIDs for 5-7 days or hormonal treatment with COCs or estrogen for 10-20 days (if medically eligible) 4

Special Considerations

• COCs increase the risk of venous thromboembolism (VTE) three to fourfold (up to 4 per 10,000 woman-years), so assess cardiovascular risk factors before prescribing 1, 2
• Long-term COC use reduces the risk of endometrial cancer, which is particularly beneficial for patients with chronic anovulation 1
• For patients with leiomyomas (fibroids), COCs may be more effective than tranexamic acid alone 3
• Avoid continuous use of COCs without withdrawal bleeds for extended periods (years), as this may lead to endometrial proliferation and subsequent heavy bleeding when discontinued 7
• Monitor blood pressure at follow-up visits for patients on COCs 4, 2

Treatment Efficacy

• Both COCs and tranexamic acid can reduce menstrual blood loss by 20-60% 3, 5
• The LNG-IUD has efficacy comparable to endometrial ablation or hysterectomy for reducing menstrual blood loss 5
• NSAIDs are less effective than tranexamic acid but still provide significant reduction in blood loss 5

If bleeding disorder persists or the patient finds it unacceptable despite medical therapy, counsel on alternative methods and consider referral for surgical management 4.