What are the treatment options for a 44-year-old woman with menorrhagia (heavy menstrual bleeding)?

Treatment of Heavy Menstrual Bleeding in a 44-Year-Old Woman

For a 44-year-old woman with heavy menstrual bleeding, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment, reducing menstrual blood loss by 71-95% and providing superior outcomes compared to all other medical therapies. 1, 2

Initial Evaluation

Before initiating treatment, evaluate for underlying pathology that requires specific management:

• Rule out structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 1
• Exclude pregnancy in all reproductive-age women with abnormal bleeding 1
• Assess for coagulopathies if clinically indicated
• Review current medications, particularly anticoagulants or antiplatelet therapy that may contribute to bleeding 1

Treatment Algorithm

First-Line: Levonorgestrel-Releasing IUD (LNG-IUD 20 μg/day)

The LNG-IUD is the single most effective medical treatment for heavy menstrual bleeding, regardless of underlying cause. 1, 2, 3

• Reduces menstrual blood loss by 71-95% 1
• Efficacy comparable to endometrial ablation 1
• Effective even with structural causes including fibroids and adenomyosis 2
• Over time, many women develop only light bleeding or amenorrhea 1
• Provides contraception as an added benefit 1
• Most cost-effective long-term option 2, 3

Second-Line: NSAIDs (If LNG-IUD Declined or Contraindicated)

NSAIDs are the recommended pharmacologic first-line treatment for women not using the LNG-IUD. 4, 1

• Dosing: 5-7 days during menstruation only 1, 4
• Effective agents: mefenamic acid, naproxen, ibuprofen, indomethacin, diclofenac 1, 4, 5
• Reduce menstrual blood loss by approximately 20-50% compared to placebo 5, 6
• Additional benefit of reducing dysmenorrhea 7, 5
• Avoid aspirin: may increase blood loss 4

Critical contraindication: Do not use NSAIDs in women with cardiovascular disease due to increased MI and thrombosis risk 1, 4

Third-Line: Tranexamic Acid

• More effective than NSAIDs at reducing blood loss 5, 6
• Typical dosing: 1-1.5g three times daily during menstruation 7
• Contraindicated in women with cardiovascular disease due to thrombosis risk 1, 4
• Consider if NSAIDs ineffective and no cardiovascular contraindications 2, 7

Fourth-Line: Combined Hormonal Contraceptives

• Second-line hormonal option after LNG-IUD 2
• Can be given as combined oral contraceptives (COCs) or transvaginal ring 2
• Short-term treatment (10-20 days) may help control acute bleeding 1
• Less effective than LNG-IUD but more effective than oral progestogens 2
• Use caution at age 44: assess cardiovascular risk factors, smoking status, and thrombosis risk before prescribing 1

Fifth-Line: Oral Progestogens

• Long-course progestogens (≥21 days per cycle) more effective than short-course 2, 3
• Cyclic oral progestin reduces bleeding by approximately 87% 1
• Short-course luteal phase progestogens (≤14 days) have limited efficacy 2, 5
• May result in irregular bleeding initially but often leads to light bleeding over time 1

Special Considerations for Perimenopausal Women

At age 44, this patient is likely perimenopausal, which has specific implications:

• Menstrual blood loss naturally increases with age 3
• LNG-IUD remains the most effective option and can be used through menopause 2, 3
• If using combined hormonal contraceptives, carefully assess cardiovascular and thrombotic risk factors 1
• Consider that surgical options (endometrial ablation, hysterectomy) may be more definitive given proximity to menopause if medical management fails 7

When Medical Management Fails

If bleeding persists despite optimal medical therapy or the woman finds it unacceptable:

• Counsel on alternative methods and offer different medical options 1
• Consider endometrial ablation as a conservative surgical option 1, 7
• Reserve hysterectomy for women with significant pelvic pathology or those unresponsive to all other treatments 2, 7

Critical Pitfalls to Avoid

• Do not use short-course luteal progestogens (10-14 days)—they have minimal efficacy for heavy menstrual bleeding 2, 5
• Avoid NSAIDs and tranexamic acid in women with cardiovascular disease 1, 4
• Do not prescribe aspirin for heavy bleeding—it may worsen blood loss 4
• Always exclude pregnancy before initiating any treatment 1
• Evaluate for endometrial pathology in women over 40 with new-onset or changing bleeding patterns before attributing symptoms to benign causes