What are the treatment options for heavy menstrual bleeding?

Treatment of Heavy Menstrual Bleeding

First-Line Medical Treatment

NSAIDs are the recommended first-line pharmacologic treatment for heavy menstrual bleeding, prescribed for 5-7 days during menstruation only. 1, 2, 3

NSAIDs as Initial Therapy

• Multiple NSAIDs have demonstrated statistically significant reductions in menstrual blood loss, including mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium 4, 1, 2
• NSAIDs reduce menstrual blood loss by approximately 40 mL per cycle compared to placebo (mean difference -40.67 mL/cycle) 5
• Treatment duration should be limited to 5-7 days during active bleeding days only 1, 2, 3
• Avoid aspirin, as it does not reduce bleeding and may actually increase blood loss in women with lower baseline menstrual blood loss 2

Critical Contraindications

• NSAIDs must be avoided in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 2, 3
• Screen for cardiovascular risk factors before initiating NSAID therapy 3

Second-Line Medical Treatment

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

The LNG-IUD is the most effective medical treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95%. 1, 2, 3

• The LNG-IUD results in a large reduction in menstrual blood loss (mean difference -105.71 mL/cycle compared to placebo) 5
• Over time, many women experience only light menstrual bleeding or amenorrhea 2
• The LNG-IUD can be used through menopause in perimenopausal women 3
• This option is particularly valuable for women who have failed NSAID therapy and desire long-term management 1, 3

Tranexamic Acid

• Tranexamic acid is a non-hormonal alternative that reduces menstrual blood loss by approximately 80 mL per cycle 1, 5
• Tranexamic acid is absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 1, 2, 3
• Consider tranexamic acid only if NSAIDs are ineffective and there are no cardiovascular or thrombotic contraindications 3

Other Hormonal Options

• Antifibrinolytics (tranexamic acid) probably reduce menstrual blood loss (mean difference -80.32 mL/cycle) 5
• Long-cycle progestogens reduce menstrual blood loss (mean difference -76.93 mL/cycle) 5
• Combined oral contraceptives have limited evidence, with one small study showing no significant difference compared to NSAIDs 6
• Short-term combined oral contraceptives (10-20 days) or estrogen may be effective for irregular bleeding in specific contexts 2

Essential Initial Assessment

Before initiating treatment, evaluate:

• Rule out pregnancy in all reproductive-age women with abnormal bleeding 1, 3
• Assess for structural causes including fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 3
• Screen for sexually transmitted diseases and new pathologic uterine conditions 1
• Evaluate for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1
• Review current medications, particularly anticoagulants or antiplatelet therapy 3
• Check for signs of hemodynamic instability 1

Treatment Algorithm

Step 1: Initial Medical Management

• Start with NSAIDs for 5-7 days during menstruation 1, 2, 3
• Reassess after 1-3 cycles 1

Step 2: If NSAIDs Fail

• Consider LNG-IUD as the most effective option (71-95% reduction in blood loss) 1, 2, 3
• Alternative: tranexamic acid if no cardiovascular contraindications 1, 3
• Alternative: long-cycle progestogens 5

Step 3: If Medical Management Fails

• Counsel on alternative methods and offer different medical options 3
• Consider endometrial ablation as a conservative surgical option 3
• Hysterectomy results in the largest reduction in bleeding but is reserved for refractory cases 5

Surgical Options for Refractory Cases

When medical management fails:

• Hysterectomy results in the largest reduction in bleeding (OR 14.31-25.71) and highest satisfaction rates (OR 7.96 for minimally invasive approach) 5
• Non-resectoscopic endometrial ablation (NREA) probably results in large reduction in menstrual blood loss (OR 2.87-3.32) and increases satisfaction (OR 1.59) 5
• Resectoscopic endometrial ablation (REA) results in large reduction in menstrual blood loss (OR 2.70) 5
• Minimally invasive hysterectomy has higher satisfaction rates than open approaches 5

Important Counseling Points

• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities with certain treatments (like copper IUD) are generally not harmful can improve treatment adherence 4, 1
• Unscheduled spotting or light bleeding is common during the first 3-6 months of copper IUD use and generally decreases with continued use 4