What is the first line of treatment for a 30-year-old woman with heavy and prolonged menstrual bleeding (menorrhagia) lasting 15 days?

First-Line Treatment for Heavy and Prolonged Menstrual Bleeding

NSAIDs (such as ibuprofen 400 mg every 4-6 hours or naproxen) prescribed for 5-7 days during active bleeding days are the recommended first-line pharmacologic treatment for this 30-year-old woman with heavy menstrual bleeding. 1, 2

Immediate Assessment Required

Before initiating treatment, you must:

• Rule out pregnancy immediately with a urine or serum pregnancy test, as this is mandatory in all reproductive-age women with abnormal bleeding 1, 2
• Assess hemodynamic stability by checking vital signs, orthostatic changes, and signs of acute blood loss 2
• Evaluate for structural causes including fibroids, polyps, adenomyosis, or endometrial pathology through pelvic examination and consider pelvic ultrasound if clinically indicated 1
• Screen for coagulopathies if there is a personal or family history of bleeding disorders, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1, 2

First-Line Treatment: NSAIDs

NSAIDs are the appropriate initial pharmacologic choice because they:

• Reduce menstrual blood loss by 25-35% through prostaglandin synthetase inhibition 1, 2, 3
• Are prescribed only during the 5-7 days of active bleeding, not continuously 1, 2
• Multiple agents are effective: mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium 1
• For ibuprofen specifically: 400 mg every 4-6 hours as needed during menstruation (do not exceed 3200 mg daily) 4

Critical Contraindications to NSAIDs

You must screen for and avoid NSAIDs in women with:

• Cardiovascular disease (increased risk of myocardial infarction and thrombosis) 1
• Active peptic ulcer disease or history of gastrointestinal bleeding 4
• Renal impairment 4
• Never use aspirin, as it does not reduce bleeding and may actually increase blood loss 1

If NSAIDs Fail After 1-3 Cycles

Second-line options include:

1. Levonorgestrel-releasing intrauterine device (LNG-IUD) - the most effective medical treatment, reducing menstrual blood loss by 71-95% 1, 2, 5, 6, 7

2. Tranexamic acid - a non-hormonal alternative reducing blood loss by approximately 80 mL per cycle, but absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 1, 2, 5

3. Combined hormonal contraceptives (oral or vaginal ring) - effective for reducing menstrual blood loss when hormonal options are appropriate 5, 7

Treatment Algorithm

Start with NSAIDs for 5-7 days during bleeding 1, 2 ↓ Reassess after 1-3 menstrual cycles 2 ↓ If bleeding persists or remains unacceptable:

• Consider LNG-IUD if patient desires long-term contraception or definitive management 1, 5
• Consider tranexamic acid if hormonal options are contraindicated 1, 2
• Consider combined hormonal contraceptives if patient desires contraception 5 ↓ If medical management fails, refer for evaluation of surgical options 2

Important Counseling Points

• Enhanced counseling about expected bleeding patterns and reassurance that initial irregularities with certain treatments (especially LNG-IUD) can improve treatment adherence 1, 2
• NSAIDs should be taken with food or milk to minimize gastrointestinal side effects 4
• The LNG-IUD may cause irregular bleeding initially but often leads to light bleeding or amenorrhea over time 1