What is the treatment for a 45-year-old female with menorrhagia (heavy periods)?

Treatment for Heavy Menstrual Bleeding in a 45-Year-Old Woman

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

Treatment Algorithm

First-Line: NSAIDs (Answer B)

• Multiple NSAIDs have demonstrated statistically significant reductions in menstrual blood loss, including mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium. 1
• NSAIDs reduce menstrual blood loss by 20-60% and should be used only during active bleeding days for 5-7 days. 2, 3
• This approach is particularly appropriate for short-term symptom management and when hormonal options are not desired. 4

Critical contraindication: NSAIDs must be avoided in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis. 1 Screen for cardiovascular risk factors before initiating therapy.

Do not use aspirin - it does not reduce bleeding and may actually increase blood loss in women with lower baseline menstrual blood loss. 1

Second-Line: Tranexamic Acid (Answer A)

• Tranexamic acid is a non-hormonal alternative that reduces menstrual blood loss by 34-59% over 2-3 cycles. 5, 6
• It is significantly more effective than NSAIDs, reducing blood loss by approximately 80 mL per cycle. 1, 6
• Recommended dosage is 3.9-4 g/day for 4-5 days starting from the first day of menstruation. 5

Absolute contraindications for tranexamic acid: Active thromboembolic disease, history of thrombosis, or cardiovascular disease. 1, 5 The FDA warns that tranexamic acid is contraindicated in women with active thromboembolic disease or with a history or intrinsic risk for thrombosis or thromboembolism. 2

Third-Line: Progesterone (Answer C)

• Cyclic oral progestins reduce bleeding by approximately 87%, though may result in irregular bleeding patterns. 4
• However, cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate. 3
• Progesterone is primarily indicated for secondary amenorrhea (absence of periods) rather than heavy bleeding. 7
• The FDA label indicates progesterone capsules are used for treatment of secondary amenorrhea due to decreased progesterone, not as first-line for heavy bleeding. 7

Most Effective Long-Term Option (Not Listed)

• The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment, reducing menstrual blood loss by 71-95%. 4, 1
• This option provides both contraception and treatment of heavy bleeding, making it ideal for women desiring long-term management. 4

Essential Initial Assessment Before Treatment

• Rule out pregnancy in all reproductive-age women with abnormal bleeding. 1, 8
• Assess for structural causes including fibroids, polyps, adenomyosis, or malignancy. 1
• Evaluate for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder. 4, 1
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss. 8

Common Pitfalls to Avoid

• Do not use cyclic progestogens as first-line treatment - they are ineffective in ovulating women despite reducing bleeding in anovulatory cycles. 3
• Avoid tranexamic acid in women with any thrombotic risk - the FDA contraindication is broader in the US than in other countries. 2, 5
• Enhanced counseling about expected bleeding patterns improves treatment adherence and reduces discontinuation. 2, 1