What treatment options are available for a female patient experiencing prolonged menstrual bleeding lasting over a month?

Management of Prolonged Menstrual Bleeding Lasting One Month

For a woman with menstrual bleeding lasting one month, immediately rule out pregnancy and structural pathology, then initiate NSAIDs for 5-7 days during bleeding episodes while simultaneously starting hormonal therapy with combined oral contraceptives or progestogens for 10-20 days if medically eligible. 1

Immediate Assessment

First, exclude pregnancy in all reproductive-age women with abnormal bleeding 2. This includes ruling out both intrauterine and ectopic pregnancy, particularly given the prolonged duration 3.

Next, assess hemodynamic stability:

• Check for tachycardia or hypotension indicating significant blood loss 3
• Evaluate for anemia with appropriate laboratory testing 4
• If bleeding is very heavy with hemodynamic compromise, urgent evaluation is required 3

Rule out underlying gynecological problems including:

• Structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 2
• Sexually transmitted infections 5, 1
• Coagulopathies if clinically indicated 2
• Medication interactions, particularly anticoagulants or antiplatelet therapy 2

Women on anticoagulation have a 32% incidence of abnormal uterine bleeding with factor Xa inhibitors 3, and up to 70% of women on anticoagulation experience heavy menstrual bleeding 4.

First-Line Medical Treatment Algorithm

Step 1: NSAIDs (5-7 Days During Bleeding)

Initiate NSAIDs immediately for 5-7 days during active bleeding episodes 5, 1. NSAIDs reduce menstrual blood loss by 20-60% and are effective regardless of whether bleeding is anovulatory or ovulatory 1, 6.

Critical caveat: Avoid NSAIDs in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 2. Never use aspirin, as it may paradoxically increase bleeding in some women 1.

Step 2: Hormonal Therapy (Concurrent with NSAIDs)

For bleeding lasting one month, NSAIDs alone are insufficient. Add hormonal therapy simultaneously:

For anovulatory bleeding (most common with prolonged bleeding):

• Combined oral contraceptives for 10-20 days 1
• OR oral progestogens (norethindrone acetate 2.5-10 mg daily for 5-10 days) 7
• Progestin withdrawal bleeding typically occurs 3-7 days after discontinuation 7

For ovulatory bleeding or if contraception is desired:

• Consider levonorgestrel-releasing intrauterine system (LNG-IUS), which reduces menstrual blood loss by 71-95% 2, 1
• This is the most effective first-line treatment overall 2, 8

Step 3: Alternative Agents if NSAIDs Contraindicated

Tranexamic acid reduces bleeding by 40-60% 1, 6 but is expensive and absolutely contraindicated in women with active thromboembolism or history of thrombosis 5, 2, 1.

Treatment Based on Current Contraceptive Use

If using copper IUD (Cu-IUD):

• Bleeding in first 3-6 months is common and generally not harmful 5, 1
• However, new-onset prolonged bleeding after months of use suggests displacement, infection, pregnancy, or new uterine pathology 5
• Treat with NSAIDs 5-7 days 5, 1

If using contraceptive implant:

• Rule out drug interactions, STIs, pregnancy, or new uterine conditions 3
• Treat with NSAIDs 5-7 days OR combined oral contraceptives 10-20 days if medically eligible 3

If using LNG-IUD:

• Initiate NSAIDs 5-7 days OR hormonal treatment with COCs/estrogen 10-20 days 1

When Initial Treatment Fails

If bleeding persists despite optimal medical therapy:

• Re-evaluate for underlying structural pathology 1
• Consider endometrial biopsy, particularly in women ≥35 years or those <35 with risk factors for endometrial cancer 9
• Transvaginal ultrasonography or saline infusion sonohysterography to evaluate for polyps and fibroids 6, 9

Counsel on alternative contraceptive methods and offer different options 5, 1. For women not seeking pregnancy, the LNG-IUS remains the most effective option and can be used through menopause 2, 10.

Second-Line Options

If medical management completely fails:

• LNG-IUS is most effective (71-95% reduction in blood loss) 2, 8
• Endometrial ablation as conservative surgical option 2
• Hysterectomy is most definitive but reserved for refractory cases 9, 8

Special Population Considerations

Perimenopausal women:

• Carefully assess cardiovascular and thrombotic risk before using combined hormonal contraceptives 2
• LNG-IUS remains most effective option and can continue through menopause 2

Women with bleeding disorders:

• Heavy menstrual bleeding affects ~90% of women with underlying bleeding disorders 4
• Flooding (changing pad/tampon more than hourly) and clots ≥1 inch suggest coagulopathy 4
• Refer to hematology if personal or family bleeding history present 4