What is the treatment and workup for a 43-year-old female experiencing menorrhagia (heavy menstrual bleeding) lasting 26 days?

From the Guidelines

For a 43-year-old female experiencing a heavy menstrual period lasting 26 days, immediate medical evaluation is necessary to rule out underlying health conditions and prevent complications. The initial workup should include:

• A complete blood count to assess for anemia
• Thyroid function tests
• A pregnancy test to rule out complications like miscarriage
• Transvaginal ultrasound to evaluate for structural causes such as fibroids, polyps, or endometrial hyperplasia 1. For immediate management, consider starting a combined oral contraceptive pill or medroxyprogesterone acetate 10mg daily for 10-14 days to stop the bleeding, as suggested by the most recent guidelines 1. Tranexamic acid 1000mg three times daily during bleeding can also help reduce flow, as it is a nonhormonal agent that has been used previously for the treatment of dysfunctional uterine bleeding 1. Iron supplementation (ferrous sulfate 325mg daily) is advisable if anemia is present. For severe bleeding causing hemodynamic instability, emergency care is needed. This prolonged heavy bleeding at age 43 could indicate perimenopause, but structural abnormalities and endometrial cancer must be ruled out, particularly given the patient's age and the abnormal bleeding pattern. After the acute episode resolves, long-term management options include hormonal contraceptives, levonorgestrel IUD, or endometrial ablation depending on the underlying cause and future fertility desires 1. It is essential to consider the patient's goals and preferences when choosing a treatment option, as emphasized in the recent guidelines 1. The patient should be counseled on alternative contraceptive methods and offered another method if desired, as suggested by the guidelines 1. Overall, the management of heavy menstrual bleeding in a 43-year-old female requires a comprehensive approach that takes into account the patient's medical history, preferences, and underlying health conditions.

From the FDA Drug Label

In case of undiagnosed, persistent or recurrent abnormal vaginal bleeding, appropriate measures should be conducted to rule out malignancy In cases of breakthrough bleeding, as in all cases of irregular bleeding per vaginum, nonfunctional causes should be borne in mind and adequate diagnostic measures undertaken.

The patient is experiencing heavy menstrual bleeding for 26 days. Given the patient's symptoms, a thorough workup is necessary to rule out any underlying conditions, including malignancy. The following steps should be taken:

• Conduct a thorough physical examination, including a pelvic exam and cervical cytology
• Perform relevant laboratory tests to rule out any underlying conditions
• Consider imaging studies to evaluate the uterus and ovaries
• Take a detailed medical history to identify any potential risk factors for malignancy or other conditions that may be contributing to the patient's symptoms. 2 2

From the Research

Heavy Menstrual Bleeding Treatment

A 43-year-old female experiencing heavy menstrual bleeding for 26 days can be treated with various medical and surgical options. The treatment approach depends on the underlying cause of the bleeding and the patient's preferences and fertility wishes.

• Medical Therapies:
  • Hormonal treatments, such as levonorgestrel-releasing intrauterine system (LNG-IUS) and combined hormonal contraceptives, are commonly used to reduce menstrual blood loss 3.
  • Tranexamic acid is an effective treatment for heavy menstrual bleeding, reducing menstrual blood loss by 26%-60% 4, 5.
  • Ulipristal acetate is an approved preoperative treatment for uterine fibroids and has demonstrated efficacy in reducing menstrual blood loss 3.
• Haemostatic Therapies:
  • Tranexamic acid and DDAVP (1-deamino-8-D-arginine) are used to reduce menstrual blood loss, with DDAVP used for heavy menstrual bleeding associated with certain inherited bleeding disorders 3.
• Surgical Options:
  • Endometrial ablation is a minor surgical procedure that can be performed as an outpatient and is associated with low operative morbidity 3.
  • Hysterectomy remains the definitive treatment of choice when medical therapies have failed and endometrial ablation is not suitable 3.

Assessment and Diagnosis

Assessment of heavy menstrual bleeding should entail a menstrual and gynaecological history and a bleeding score to distinguish those women who require additional haematological investigations 3. A pelvic examination and ultrasound scan can help rule out the presence of any underlying pathology 3.

Comparison of Treatments

• LNG-IUS vs. Other Medical Therapies: The LNG-IUS may improve heavy menstrual bleeding and quality of life compared to other medical therapies, with a reduction in menstrual blood loss of up to 90% 6.
• LNG-IUS vs. Endometrial Ablation: The LNG-IUS is probably similar to endometrial ablation in terms of reducing heavy menstrual bleeding, but may have a higher risk of treatment failure and adverse events 6.
• LNG-IUS vs. Hysterectomy: The LNG-IUS may be less effective than hysterectomy in reducing heavy menstrual bleeding, but has a lower risk of serious adverse events and treatment failure 6.