What is the treatment for prolonged menstruation?

Treatment of Prolonged Menstruation

First-line treatment for prolonged menstrual bleeding is combined oral contraceptives containing 30-35 μg ethinyl estradiol (with levonorgestrel or norgestimate), which reduces menstrual blood loss by inducing regular shedding of a thinner endometrium. 1

Initial Evaluation Before Treatment

Before initiating any therapy, you must rule out underlying pathology 1:

• Pregnancy - always exclude first 1
• Sexually transmitted infections - particularly critical in reproductive-aged women 1
• Structural lesions - fibroids, polyps, or other uterine abnormalities 1, 2
• Malignancy - especially if bleeding is persistent or recurrent 2

First-Line Medical Treatment

Combined oral contraceptives (COCs) are the primary medical therapy 1:

• Use monophasic formulations containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 1
• COCs reduce menstrual blood loss by 12% to 77% compared to 3% with placebo 3
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 1
• Screen for thrombotic risk factors before prescribing, as COCs increase venous thromboembolism risk three to fourfold 1

Management of Persistent Bleeding

If bleeding continues despite COC therapy 4, 5:

Reassurance phase (first 3-6 months):

• Unscheduled bleeding is common during initial months of hormonal therapy and generally not harmful 1, 5
• Continue current therapy unless bleeding is unacceptable to the patient 5

Active treatment for persistent bleeding 4, 5:

• NSAIDs for 5-7 days during bleeding episodes (first-line adjunctive therapy) 4, 1, 5
• Hormonal treatment for 10-20 days if medically eligible: additional COCs or estrogen 4, 5

For extended/continuous COC regimens 4, 5:

• Consider a hormone-free interval of 3-4 consecutive days for heavy bleeding 5
• Do NOT use hormone-free intervals during the first 21 days of extended/continuous regimens 4, 5
• Do NOT use more than once per month as contraceptive effectiveness may be reduced 4, 5

Alternative Medical Options

If COCs fail or are contraindicated 3, 6:

• Levonorgestrel-releasing intrauterine system (LNG-IUS) - more effective than COCs at reducing menstrual blood loss (OR 0.21,95% CI 0.09 to 0.48) 3
• Tranexamic acid - reduces menstrual blood loss by 20-60% 7, 6
• NSAIDs alone (mefenamic acid, naproxen) - reduce blood loss by 20-60% 7, 6

When to Change Methods

If bleeding persists despite treatment and the woman finds it unacceptable 4, 5:

• Counsel on alternative contraceptive methods 4, 5
• Offer another method if desired 4, 5
• Re-evaluate for underlying gynecological problems 5

Follow-Up Recommendations

No routine follow-up visit is required 1, 5, but patients should return for:

• Side effects or concerns 1, 5
• Assessment of satisfaction with current method 5
• Evaluation of health status changes that might affect eligibility 5
• Blood pressure monitoring at follow-up visits 1, 5

Critical Pitfalls to Avoid

• Never assume bleeding is benign - always exclude pregnancy, infection, and structural pathology first 1, 2
• Do not change to higher estrogen formulations unnecessarily - this increases thromboembolic risk 2
• Do not discontinue therapy prematurely - bleeding irregularities in the first 3-6 months are expected and not harmful 1, 5
• Avoid hormone-free intervals in the first 21 days of extended regimens or more than once monthly 4, 5