What are the treatment options for ongoing menstrual period management?

Treatment of Ongoing Menstrual Period

For women experiencing heavy or prolonged menstrual bleeding during an ongoing period, NSAIDs (such as ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) taken with food for 5-7 days during bleeding are the first-line treatment. 1

Initial Assessment

Before initiating treatment, evaluate for underlying conditions that may require specific management:

• Rule out pregnancy if clinically indicated 1
• Assess for structural abnormalities including fibroids, polyps, or other pathologic uterine conditions 1
• Screen for sexually transmitted infections 1
• Check for IUD displacement if the patient uses an intrauterine device 2

First-Line Pharmacological Treatment

NSAID Therapy

NSAIDs are more effective than placebo at reducing menstrual blood loss and should be the initial treatment approach 3, 4:

• Ibuprofen 600-800 mg every 6-8 hours with food 1
• Naproxen 440-550 mg every 12 hours with food 1
• Mefenamic acid is also effective for 5-day treatment courses 1
• Treatment duration should be short-term (5-7 days) during days of bleeding 2, 1

Evidence Supporting NSAIDs

Multiple studies demonstrate that NSAIDs reduce prostaglandin levels, which are elevated in women with excessive menstrual bleeding 5, 3. As a class, NSAIDs significantly reduce menstrual blood loss compared to placebo 3, 4.

Second-Line Options

When NSAIDs Fail

Approximately 18% of women with dysmenorrhea are unresponsive to NSAIDs 1, 6. If bleeding persists despite adequate NSAID therapy:

• Tranexamic acid is more effective than NSAIDs at reducing menstrual blood loss 3
• Mefenamic acid resulted in less blood loss compared to tranexamic acid (mean difference -64.26 mL), though both are effective 7
• Hormonal contraceptive methods should be considered if bleeding irregularities persist and are unacceptable despite treatment 1

Adjunctive Non-Pharmacological Treatments

These can be used alongside NSAIDs to enhance symptom relief:

• Heat therapy applied to the abdomen or back may reduce cramping pain 1
• Acupressure on specific points (Large Intestine-4 point on the dorsum of the hand and Spleen-6 point approximately 4 fingers above the medial malleolus) can help with pain relief 1
• Peppermint essential oil has been shown to decrease dysmenorrhea symptoms 1

Special Considerations for IUD Users

Copper IUD Users

Women with copper IUDs commonly experience increased menstrual bleeding, especially during the first 3-6 months of use 2:

• NSAIDs remain first-line treatment for Cu-IUD-associated bleeding 2, 4
• Vitamin B1 resulted in fewer pads used per day (mean difference -7.00) and fewer bleeding days (mean difference -2.00 days) compared to placebo 7
• The IUD does not need to be removed unless bleeding persists and is unacceptable to the patient after treatment 2

LNG-IUD Users

Levonorgestrel IUD users typically experience irregular bleeding that decreases over time 2:

• Unscheduled spotting or light bleeding is expected during the first 3-6 months and is generally not harmful 2
• Over time, bleeding generally decreases with many women experiencing only light menstrual bleeding or amenorrhea 2

Treatment Algorithm

1. Confirm no underlying pathology (pregnancy, STI, structural abnormalities, IUD displacement) 2, 1
2. Initiate NSAID therapy (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) for 5-7 days during bleeding 1
3. Add adjunctive therapies (heat, acupressure) as desired 1
4. If NSAIDs fail after adequate trial, consider tranexamic acid as second-line therapy 7, 4
5. If bleeding persists and is unacceptable, counsel on alternative contraceptive methods or hormonal treatments 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for the next menstrual period to assess response; NSAIDs work during active bleeding 2
• Ensure adequate dosing and duration; subtherapeutic doses or insufficient treatment duration (less than 5 days) may lead to perceived treatment failure 1
• Do not remove an IUD immediately for bleeding without first attempting medical management 2
• Recognize that approximately 18% of women will not respond to NSAIDs and require alternative therapy 1, 6

When to Consider Hormonal Treatment

If bleeding irregularities persist despite NSAID therapy and are unacceptable to the patient, hormonal contraceptive methods should be considered 1:

• Combined oral contraceptives may be appropriate for severe cases unresponsive to NSAIDs 1
• Levonorgestrel-releasing IUS is more effective than NSAIDs at reducing heavy menstrual bleeding 3
• For suspected endometriosis, medical management with progestins, oral contraceptives, or GnRH agonists may be appropriate 1