What are the treatment options for heavy menstrual bleeding?

Treatment Options for Heavy Menstrual Bleeding

The most effective first-line treatment for heavy menstrual bleeding is the levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95% while providing contraception. 1

First-Line Treatment Options

• Levonorgestrel-releasing IUD (LNG-IUD): Most effective first-line treatment, reducing menstrual blood loss by 71-95% 1, 2
• NSAIDs for short-term treatment (5-7 days) during days of bleeding:
  • Ibuprofen: 400 mg every 4-6 hours as needed for dysmenorrhea 3
  • Naproxen and other NSAIDs have been shown to significantly reduce mean total menstrual blood loss 4, 2
• Tranexamic acid: Non-hormonal option that reduces bleeding by 26-60%, more effective than NSAIDs and oral progestins 5, 6
  • Typical dosage: 3.9-4 g/day for 4-5 days starting from the first day of menstrual cycle 5
  • Contraindicated in women with active thromboembolic disease or history of thrombosis 2, 5

Second-Line Treatment Options

• Cyclic oral progestins: Reduce bleeding by approximately 87%, though may result in irregular bleeding patterns 1
• Combined hormonal contraceptives: Effective for reducing menstrual blood loss when hormonal options are appropriate 2
• Antifibrinolytic agents (e.g., tranexamic acid): Reduce bleeding symptoms in patients with fibroids or other causes of heavy bleeding 4

Treatment Algorithm

1. Initial assessment:

   • Evaluate severity of bleeding (bleeding that saturates a large pad or tampon hourly for ≥4 hours requires urgent evaluation) 1
   • Rule out pregnancy in reproductive-age women 1, 2
   • Check for signs of hemodynamic instability (tachycardia, hypotension) 1
   • Evaluate for underlying gynecological problems (STDs, uterine conditions like polyps or fibroids) 4, 2

2. First-line treatment:

   • For women desiring contraception or long-term solution: LNG-IUD 1, 2
   • For short-term symptom management: NSAIDs for 5-7 days during bleeding 4, 2
   • For non-hormonal option: Tranexamic acid for 4-5 days starting from first day of cycle 5, 7

3. If bleeding persists after first-line treatment:

   • Consider alternative medical treatments or combination therapy 4
   • For Cu-IUD users with heavy bleeding: NSAIDs for 5-7 days 4
   • For implant users with heavy bleeding: NSAIDs, hormonal treatment with low-dose COCs, or tranexamic acid 4

4. For refractory cases:

   • Consider endometrial ablation techniques when medical treatment fails 1
   • Hysterectomy is a definitive treatment when other options have failed 1

Comparative Effectiveness

• Tranexamic acid reduces menstrual blood loss by 54% compared to 20% reduction with mefenamic acid (an NSAID) 6
• LNG-IUD is more effective than tranexamic acid for reducing menstrual blood loss 5
• Tranexamic acid is significantly more effective than placebo, NSAIDs, and oral cyclical luteal phase progestins 5, 7

Special Considerations

• Enhanced counseling about expected bleeding patterns improves treatment adherence 4
• If bleeding remains unacceptable despite treatment, counsel on alternative methods or refer for surgical management 4
• Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 2
• Tranexamic acid significantly improves quality of life in women treated for heavy menstrual bleeding 5, 8

Common Pitfalls and Caveats

• Avoid tranexamic acid in women with active thromboembolic disease or history of thrombosis 2, 5
• NSAIDs should be used at the lowest effective dose for the shortest duration to minimize gastrointestinal side effects 3, 9
• For Cu-IUD users, unscheduled spotting or light bleeding, as well as heavy bleeding, is common during the first 3-6 months and generally decreases with continued use 4
• Hormone-free intervals are not recommended more than once per month for CHC users on extended or continuous regimens as contraceptive effectiveness might be reduced 4