What are the treatment options for menstrual clots?

Treatment of Menstrual Clots and Heavy Menstrual Bleeding

For women with menstrual clots and heavy bleeding, NSAIDs for 5-7 days during menstruation are the recommended first-line treatment, with tranexamic acid for 5 days as an equally effective alternative or addition. 1, 2

Initial Assessment

Before starting treatment, evaluate for:

• Pregnancy status - must be excluded in all reproductive-age women with abnormal bleeding 2
• Clot characteristics - clots ≥1 inch diameter strongly predict heavy menstrual bleeding and warrant treatment 3
• "Flooding" pattern - changing pad/tampon more frequently than hourly indicates significant blood loss 3
• Ferritin levels - low ferritin suggests chronic heavy bleeding 3
• Underlying bleeding disorders - personal or family history of bleeding, especially with flooding or prolonged menses, requires hematology referral 3
• Structural causes - fibroids, polyps, adenomyosis, or endometrial pathology via pelvic exam and/or imaging 2
• Coagulopathies - up to 20% of women with heavy menstrual bleeding have an inherited bleeding disorder 4

First-Line Medical Treatment

NSAIDs (Preferred Initial Option)

• Use for 5-7 days during menstruation only 1, 2
• Reduces menstrual blood loss by 20-60% 1
• Critical contraindication: Avoid in women with cardiovascular disease due to increased MI and thrombosis risk 5, 2

Tranexamic Acid (Equally Effective Alternative)

• Use for 5 days during menstruation 1, 2
• Reduces menstrual blood loss by 20-60% 1
• Critical contraindication: Contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 5, 2

Most Effective Long-Term Treatment

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is the single most effective treatment for heavy menstrual bleeding, reducing blood loss by 71-95%. 5, 2, 6

• Efficacy comparable to endometrial ablation 5
• Approximately 50% of users achieve amenorrhea or oligomenorrhea by 2 years 5, 7
• Effective for both endometrial dysfunction and structural causes like fibroids and adenomyosis 6
• Should be first-line for women not seeking immediate pregnancy 6

Treatment Algorithm

1. Start with NSAIDs 5-7 days during menstruation (if no cardiovascular contraindications) 1, 2

2. Add tranexamic acid 5 days during menstruation if inadequate response (if no thrombotic risk factors) 1

3. Consider LNG-IUD if medical therapy inadequate or for long-term management 2, 6

4. Alternative hormonal options if above fail:

   • Combined oral contraceptives for 10-20 days 5, 7
   • Depot medroxyprogesterone acetate (DMPA) injectable 1
   • Cyclic oral progestins (≥3 weeks per cycle) reduce bleeding by 87% 5

Special Populations

Women with Cardiovascular Disease

• Avoid NSAIDs and tranexamic acid due to MI and thrombosis risk 5, 2
• LNG-IUD is preferred as it has minimal systemic absorption and main effect is local at endometrium 5
• Consider endometrial ablation if medical management fails 5, 2

Women on Anticoagulation

• Approximately 70% experience heavy menstrual bleeding 3
• Assess for over-anticoagulation 3
• Hemostatic therapy may be life-saving when correcting coagulation abnormalities 3

When to Refer

• Hematology referral: Heavy bleeding with flooding, prolonged menses, or personal/family bleeding history 3
• Gynecology referral: Structural pathology identified, or medical management failure requiring surgical intervention 2, 4

Common Pitfalls

• Do not use short-course oral progestins (≤14 days per cycle) - these are less effective than other options 6
• Do not use aspirin - it increases menstrual blood loss rather than reducing it 5
• Counsel patients about expected bleeding patterns with LNG-IUD (spotting first 3-6 months, then decreased bleeding) to prevent premature discontinuation 5, 7