What is the treatment for prolonged menstrual bleeding lasting 3 weeks?

Treatment of Prolonged Menstrual Bleeding (3 Weeks Duration)

The first-line approach is to rule out pregnancy, structural pathology (polyps, fibroids, malignancy), and systemic causes (thyroid dysfunction, coagulation disorders), then initiate NSAIDs for 5-7 days while considering hormonal therapy based on the underlying etiology. 1

Initial Evaluation

Before initiating treatment, you must exclude:

• Pregnancy - Always rule this out first 2
• Structural causes - Endometrial polyps, submucosal fibroids, adenomyosis, or malignancy via transvaginal ultrasound or saline infusion sonohysterography 2, 3
• Endometrial pathology - Perform endometrial biopsy if the patient is ≥35 years old with recurrent anovulation, <35 years with endometrial cancer risk factors, or has bleeding unresponsive to initial medical therapy 2
• Systemic disorders - Check thyroid function, coagulation studies (especially von Willebrand disease if there's personal/family bleeding history), and prolactin levels 2, 4

Clinical red flags requiring immediate evaluation: Flooding (changing pad/tampon more than hourly), clots ≥1 inch diameter, low ferritin, or personal/family history of bleeding disorders warrant hematology referral 4

Medical Treatment Algorithm

First-Line Therapy: NSAIDs

• Initiate NSAIDs for 5-7 days during bleeding episodes - Options include mefenamic acid, indomethacin, flufenamic acid, or diclofenac 1
• NSAIDs reduce menstrual blood loss by 20-60% and are effective regardless of whether bleeding is anovulatory or ovulatory 1, 3
• Do not use aspirin - It may paradoxically increase bleeding in some women 1

Second-Line Hormonal Therapy

The choice depends on contraceptive needs and bleeding pattern:

For Anovulatory Bleeding (Irregular, Unpredictable):

• Combined oral contraceptives (COCs) or oral progestogen for 21 days per month to regulate cycles 2, 5
• If the patient is using contraception and bleeding persists, add COCs or estrogen for 10-20 days 1

For Ovulatory Bleeding (Regular but Heavy):

• Levonorgestrel-releasing intrauterine system (LNG-IUS, 20 μg/day) is the most effective option, reducing menstrual blood loss by 71-95% 6, 5
• The LNG-IUS has efficacy comparable to endometrial ablation and is superior to oral progestogens 6, 5
• Tranexamic acid reduces bleeding by 40-60% but is expensive and contraindicated in women with active or history of thromboembolism 1, 7, 3
• Oral progestogens (≥21 days per cycle) are moderately effective 2, 5

Third-Line Options

If medical management fails after appropriate trial:

• Surgical interventions - Polypectomy, fibroidectomy, uterine artery embolization, or endometrial ablation for structural causes 2
• Hysterectomy remains the most definitive treatment when other options fail 2, 7

Treatment Based on Contraceptive Use

If the patient is already using contraception and develops prolonged bleeding:

• Cu-IUD users: NSAIDs 5-7 days 1
• LNG-IUD users: NSAIDs 5-7 days OR hormonal treatment with COCs/estrogen 10-20 days (if medically eligible) 1
• Implant users: NSAIDs 5-7 days 1
• DMPA users: Hormone-free interval 3-4 days, then NSAIDs 5-7 days OR COCs/estrogen 10-20 days 1

Special Considerations

• Women on antiplatelet therapy: LNG-IUD is particularly effective, reducing blood loss by 71-95% 6
• Contraindications to hormonal therapy: Active thromboembolism, undiagnosed vaginal bleeding, pregnancy, or liver disease 6
• Persistent bleeding despite treatment: Re-evaluate for underlying pathology (fibroids, polyps, endometrial hyperplasia) and consider alternative contraceptive methods if current method is unacceptable 1, 6

Common Pitfalls

• Cyclic progestogens for <14 days are ineffective for ovulatory bleeding - Use ≥21 days per cycle 5, 3
• Bleeding in first 3-6 months of IUD use is common and generally not harmful - Counsel patients about expected patterns to reduce discontinuation 1
• Don't delay endometrial biopsy in women ≥35 years or those with risk factors for endometrial cancer 2