Treatment for Heavy Menstrual Bleeding
First-Line Medical Treatment
For women with heavy menstrual bleeding, start with NSAIDs (such as mefenamic acid, naproxen, or ibuprofen) for 5-7 days during menstruation, which reduces menstrual blood loss by approximately 20-50%. 1, 2
NSAIDs as Initial Therapy
- NSAIDs reduce prostaglandin levels, which are elevated in women with heavy menstrual bleeding, and work by decreasing menstrual blood flow during active bleeding days 2
- Multiple NSAIDs have demonstrated efficacy: mefenamic acid, naproxen, ibuprofen, indomethacin, flufenamic acid, and diclofenac sodium all show statistically significant reductions in mean menstrual blood loss 3, 1
- Treatment should be limited to 5-7 days during bleeding episodes to minimize side effects 1, 4
- NSAIDs are more effective than placebo but less effective than tranexamic acid or hormonal options 2
When NSAIDs Fail or Are Insufficient
If bleeding persists after 1-3 cycles of NSAID therapy, escalate to hormonal options 1:
Second-Line Medical Treatment
The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment, reducing menstrual blood loss by 71-95%, and should be offered as second-line therapy for women not seeking immediate pregnancy. 1, 5, 6
Hormonal Treatment Options (in order of effectiveness):
LNG-IUS (20 μg/24 hours): Most effective medical option, reduces bleeding by 71-95% and works for both dysfunctional bleeding and structural causes like fibroids and adenomyosis 1, 5, 6
Combined oral contraceptives (30-35 μg ethinyl estradiol): Second-line hormonal option, reduces menstrual blood loss by inducing regular shedding of thinner endometrium; formulations with levonorgestrel or norgestimate preferred 4, 5, 6
Tranexamic acid: Non-hormonal alternative that significantly reduces blood loss, but contraindicated in women with active thromboembolic disease or history/risk of thrombosis 3, 1, 2
Long-cycle oral progestogens (≥3 weeks per cycle): Less effective than above options but may be sufficient for some women 5, 6
Important Caveat About Short-Cycle Progestogens
- Luteal phase progestogens (≤14 days per cycle) show minimal effectiveness and should not be routinely used 6, 2
Critical Assessment Before Treatment
Before initiating any treatment, rule out 1, 4:
- Pregnancy in all reproductive-age women
- Hemodynamic instability requiring urgent intervention
- Underlying gynecological pathology: sexually transmitted infections, uterine polyps, fibroids, adenomyosis, endometrial hyperplasia/malignancy
- Inherited bleeding disorders: present in up to 20% of women with heavy menstrual bleeding 1
- Medication interactions that may affect bleeding
Surgical Treatment (Third-Line)
If medical management fails after adequate trial (typically 3-6 months) and bleeding remains unacceptable, refer for surgical evaluation. 1, 5
Surgical Options (in order of effectiveness for bleeding reduction):
- Hysterectomy (any route): Most definitive treatment with highest satisfaction rates 5
- Resectoscopic endometrial ablation (REA): Effective for bleeding reduction 5
- Non-resectoscopic endometrial ablation (NREA): Comparable efficacy to REA with potentially easier recovery 5
Treatment Algorithm Summary
Step 1: NSAIDs for 5-7 days during menstruation for 1-3 cycles 1, 4
Step 2 (if inadequate response):
- For women not seeking pregnancy: LNG-IUS as first choice, combined oral contraceptives as second choice 1, 6
- For women seeking pregnancy: Tranexamic acid (if no contraindications) or long-cycle progestogens 1, 5
Step 3 (if medical management fails): Counsel on surgical options and refer for evaluation 1, 5
Counseling Considerations
- Enhanced counseling about expected bleeding patterns improves treatment adherence and reduces discontinuation rates 3, 4
- Reassure patients that irregular bleeding during the first 3-6 months of hormonal therapy is common and generally not harmful 3, 4
- Assess thrombotic risk factors before prescribing combined oral contraceptives, as they increase venous thromboembolism risk three to fourfold 4