How is a prolonged menstrual cycle managed?

Management of Prolonged Menstrual Cycle

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment for prolonged menstrual bleeding, reducing menstrual blood loss by 71-95% and offering efficacy comparable to endometrial ablation. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, rule out the following conditions:

• Pregnancy - must be excluded first 1
• Structural causes - fibroids, polyps, adenomyosis via pelvic ultrasound 1, 2
• Malignancy - particularly in women over 40 or with risk factors 3, 1
• Coagulopathy - up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 4
• Sexually transmitted infections - especially if new onset bleeding 3

Treatment Algorithm

First-Line: Levonorgestrel-Releasing IUD (LNG-IUD)

The LNG-IUD represents the optimal first-line treatment for women seeking both contraception and management of prolonged bleeding. 2

• Three FDA-approved options are equally effective: Mirena (52 mg), Liletta (52 mg), and Skyla (13.5 mg levonorgestrel) 2
• Expect initial irregular bleeding for 3-6 months, which typically resolves with continued use 3, 2
• Many women develop amenorrhea, which is safe and often desired 2
• Efficacy is comparable to endometrial ablation but preserves fertility 1

Special consideration: Nulliparous women are excellent candidates despite older concerns, and the LNG-IUD does not cause infertility 2

Second-Line: Combined Hormonal Contraceptives (CHCs)

If LNG-IUD is not suitable or desired:

• Extended or continuous cycles are more effective than cyclic use for reducing menstrual blood loss 3, 2
• Can be used for 10-20 days to acutely manage heavy bleeding episodes 2
• Common transient side effects include irregular bleeding, headache, and nausea during the first 3-6 months 3
• Contraindications include: smoking in women ≥35 years, history of thromboembolism, uncontrolled hypertension, or active liver disease 5

Third-Line: Non-Hormonal Options

NSAIDs (e.g., ibuprofen, mefenamic acid):

• Reduce menstrual blood loss by 20-60% 6
• Use for 5-7 days during bleeding episodes 3, 1
• Avoid aspirin as it may increase bleeding 2

Tranexamic acid:

• Reduces menstrual blood loss by 20-60% 6
• Particularly useful for women who cannot use hormonal methods 4

Fourth-Line: Progestin-Only Pills

• Less effective than LNG-IUD or CHCs but may reduce bleeding in some women 2
• Require strict daily adherence, which affects efficacy 2
• Important caveat: Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 6

Managing Breakthrough Bleeding

If irregular bleeding persists despite treatment:

First-line approach:

• NSAIDs for 5-7 days during bleeding episodes 1, 2

Second-line approach (if NSAIDs fail):

• Short course of estrogen or CHCs for 10-20 days 2
• Consider a 3-4 day hormone-free interval for women on extended/continuous CHCs, which can improve bleeding patterns 3

If bleeding remains unacceptable:

• Counsel on alternative contraceptive methods and offer another method if desired 3, 1

Critical Pitfalls to Avoid

1. Do not attribute prolonged bleeding to hormonal causes without excluding structural pathology, especially in women over 40 3, 1

2. Do not use cyclic progestogens as first-line treatment - they are ineffective for reducing menstrual bleeding in ovulatory women 6

3. Do not prescribe CHCs containing ethinyl estradiol to women receiving Hepatitis C treatment with ombitasvir/paritaprevir/ritonavir - this combination significantly increases risk of liver enzyme elevations 5

4. Counsel patients about expected bleeding patterns - enhanced counseling about initial irregular bleeding (first 3-6 months) reduces method discontinuation 3

5. For women with severe thrombocytopenia or bleeding disorders, the LNG-IUD is particularly beneficial as it treats both heavy bleeding and reduces bleeding risk 2

When to Consider Surgical Options

If medical therapies fail and the patient finds bleeding unacceptable:

• Endometrial ablation - low operative morbidity, can be performed as outpatient 4
• Hysterectomy - definitive treatment when medical therapies have failed and endometrial ablation is not suitable 4