What is the appropriate treatment for a 38-year-old female with a 3-week menstrual period?

Treatment of Prolonged Menstrual Bleeding in a 38-Year-Old Woman

For a 38-year-old woman experiencing a 3-week menstrual period, first rule out underlying pathology (pregnancy, infection, structural lesions), then initiate combined oral contraceptives containing 30-35 μg ethinyl estradiol as first-line treatment, which effectively reduces menstrual blood loss by inducing regular shedding of a thinner endometrium. 1

Initial Diagnostic Evaluation

Before initiating treatment, you must exclude:

• Pregnancy - obtain hCG testing 2
• Sexually transmitted infections - particularly in reproductive-aged women 3
• Structural pathology - polyps, fibroids, or other uterine conditions 3
• Medication interactions - particularly with other hormones or anticoagulants 3
• Bleeding disorders - especially if she has history of heavy bleeding since menarche, family history, or other bleeding symptoms 4

Perform pelvic ultrasound (transvaginal and suprapubic) as first-line imaging to identify structural causes 2. Check complete blood count to assess for anemia given the prolonged bleeding duration 2.

First-Line Medical Management

Monophasic combined oral contraceptives are the recommended initial therapy:

• Formulation: Use pills containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 1
• Mechanism: These decrease menstrual blood loss and cramping by inducing regular shedding of a thinner endometrium 1
• Additional benefits: Improvement in acne, reduced risk of endometrial and ovarian cancers 1

Dosing Strategy for Acute Bleeding

For ongoing heavy bleeding, consider:

• NSAIDs for 5-7 days to reduce blood flow acutely 1, 5
• Start combined oral contraceptives immediately (do not wait for bleeding to stop) 1

Alternative First-Line Options

If combined oral contraceptives are not suitable:

• Tranexamic acid - particularly effective when hormones are contraindicated or immediate pregnancy is desired 2
• Levonorgestrel IUD - most effective long-term option for heavy menstrual bleeding, though requires placement 2

Management of Persistent Bleeding on Hormonal Therapy

If breakthrough bleeding continues after initiating combined oral contraceptives:

• Reassure that unscheduled bleeding is common during the first 3-6 months and generally not harmful 3
• Re-evaluate for underlying gynecological problems if bleeding persists beyond initial months 3
• Consider 3-4 day hormone-free interval if using extended regimens, but NOT during the first 21 days of use and not more than once per month 3, 1
• Add NSAIDs for 5-7 days during bleeding episodes 1, 5

Second-Line Options

If combined oral contraceptives fail or are contraindicated:

• Depot medroxyprogesterone acetate (DMPA) - amenorrhea is common after ≥1 year of continuous use 1, 5
• Etonogestrel implant - for persistent bleeding with implant, use NSAIDs for 5-7 days for spotting, or consider hormonal treatment (low-dose COCs or estrogen) for 10-20 days for heavy bleeding 5

Critical Safety Considerations

Assess thrombotic risk factors before prescribing combined oral contraceptives:

• COCs increase venous thromboembolism risk three to fourfold (up to 4 per 10,000 woman-years) 1
• Contraindications include history of DVT/PE, smoking over age 35, migraine with aura, uncontrolled hypertension 6
• Monitor blood pressure at follow-up visits 1, 5

Follow-Up Protocol

• No routine follow-up required, but patient should return for side effects or concerns 1, 5
• At follow-up visits, assess satisfaction with method and any health status changes 1, 5
• If bleeding remains unacceptable despite medical management, counsel on alternative methods or consider referral for surgical evaluation 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for "natural resolution" - 3 weeks of bleeding warrants immediate intervention to prevent anemia 2
• Do not prescribe hormone-free intervals during the first 21 days of continuous hormonal contraceptive use, as this reduces contraceptive effectiveness 3, 1
• Do not overlook bleeding disorders - von Willebrand disease affects 32-100% of women with menorrhagia and requires specific testing during menstruation 4
• Do not assume all bleeding is benign - always exclude pregnancy, infection, and structural pathology before attributing bleeding to dysfunctional causes 3, 2