What can be done to manage increased menstrual blood flow in a patient with irregular menses?

Management of Heavy Menstrual Bleeding in a 50-Year-Old Woman

For this 50-year-old woman with heavy menstrual bleeding after months of amenorrhea, start with NSAIDs (ibuprofen 400 mg every 4-6 hours or mefenamic acid 500 mg three times daily for 5 days) as first-line treatment while simultaneously ruling out endometrial pathology given her age and bleeding pattern. 1, 2

Immediate Assessment Required

Given this patient's age (50 years) and pattern of bleeding (heavy period after months of amenorrhea), endometrial evaluation is critical before initiating treatment. 3, 4

• Endometrial biopsy is indicated because she is over 35 years with irregular menses and represents a perimenopausal bleeding pattern that requires exclusion of endometrial hyperplasia or malignancy 3, 4
• Rule out pregnancy with beta-hCG testing despite her age and irregular cycles 3
• Check TSH and prolactin levels, as thyroid dysfunction commonly causes irregular bleeding in this age group 3, 4
• Assess for anemia with CBC given the heavy bleeding this morning 5
• Transvaginal ultrasonography should be performed to evaluate for structural causes (polyps, fibroids, endometrial thickness) 4, 6

First-Line Medical Treatment

NSAIDs are the recommended first-line treatment for acute heavy bleeding: 1, 3

• Ibuprofen 400 mg every 4-6 hours during bleeding days (maximum 3200 mg daily) reduces menstrual blood loss by 20-60% 7, 6
• Alternative: Mefenamic acid 500 mg three times daily for 5 days has demonstrated significant reduction in bleeding 2, 1
• NSAIDs work by inhibiting prostaglandin synthesis and reducing menstrual blood flow 3, 6

Important caveat: Avoid aspirin as it may paradoxically increase bleeding in some women 1

Second-Line Options if NSAIDs Insufficient

If bleeding persists after 5-7 days of NSAID therapy: 1, 8

• Tranexamic acid reduces menstrual blood loss significantly but is contraindicated if she has cardiovascular disease risk factors (note her hypertension and hyperlipidemia) 3, 1
• Short course of combined oral contraceptives (10-20 days) if medically eligible, though her age, hypertension, and hyperlipidemia may represent contraindications 2, 8
• Cyclic progestin therapy (oral progesterone for 21 days per month) is effective for ovulatory bleeding 4, 6

Long-Term Management Consideration

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the most effective long-term medical treatment, reducing menstrual blood loss by 71-95% and often resulting in amenorrhea over time 1, 4, 6

Referral Indications

Refer to gynecology if: 3, 4

• Endometrial biopsy shows hyperplasia with atypia or malignancy (refer to gynecologic oncologist for malignancy) 3
• Medical management fails after 3 months 4
• Structural lesions requiring surgical intervention are identified (polyps, submucosal fibroids) 4, 6
• Bleeding causes severe anemia unresponsive to oral iron supplementation 5

Critical Pitfalls to Avoid

• Do not assume this is simple perimenopausal bleeding without tissue diagnosis - abnormal bleeding in perimenopausal women must exclude malignancy 9
• Do not use cyclic progestins alone as first-line - they are ineffective for reducing bleeding in ovulatory women 6
• Avoid tranexamic acid in this patient given her cardiovascular risk factors (hypertension, hyperlipidemia) due to thrombosis risk 1
• Do not delay endometrial assessment - the combination of age >45 years plus irregular bleeding after amenorrhea is high-risk for endometrial pathology 3, 4