What is the treatment for a patient with prolonged menstrual bleeding lasting over 14 days?

Treatment of Prolonged Menstrual Bleeding (>14 Days)

For a patient with menstrual bleeding lasting over 14 days, first rule out pregnancy and underlying gynecological pathology (pregnancy, structural lesions, infection, malignancy), then initiate treatment with NSAIDs (naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours) for 5-7 days during bleeding, or tranexamic acid if NSAIDs fail or are contraindicated. 1, 2

Initial Assessment and Diagnostic Workup

Before initiating treatment, you must systematically exclude serious underlying conditions:

Immediate Evaluation Required

• Pregnancy test (β-hCG) in all reproductive-age women—this is mandatory before any treatment 2, 3
• Assess hemodynamic stability: bleeding saturating a large pad/tampon hourly for ≥4 hours warrants urgent evaluation 2
• Physical examination: speculum exam to visualize cervix/vagina and exclude cervical or vaginal bleeding sources; bimanual exam to assess uterine size and adnexal masses 2

Rule Out Structural and Pathological Causes

• Transvaginal ultrasound with Doppler is the first-line imaging study to identify polyps, fibroids, adenomyosis, or endometrial hyperplasia/malignancy 2
• Consider pregnancy, STDs, IUD displacement (if applicable), and new pathologic uterine conditions (polyps, fibroids) 4
• In postmenopausal women or those with risk factors (obesity, diabetes, unopposed estrogen), endometrial cancer must be excluded 2

Critical pitfall: Do not assume this is simple dysfunctional bleeding without excluding structural pathology—up to 50% of menorrhagia cases have identifiable pathology, and 20% may have an underlying bleeding disorder 1, 5

First-Line Medical Treatment

Once serious pathology is excluded, proceed with medical management:

NSAIDs (Preferred Initial Treatment)

• Naproxen 440-550 mg every 12 hours OR ibuprofen 600-800 mg every 6-8 hours, taken with food 1, 6
• Duration: 5-7 days during active bleeding only 4, 1, 6
• NSAIDs reduce menstrual blood loss by 20-60% through prostaglandin inhibition 4, 5, 7
• Multiple studies demonstrate statistically significant reductions in mean menstrual blood loss with mefenamic acid, indomethacin, flufenamic acid, and diclofenac 4

Important caveat: Avoid NSAIDs in patients with cardiovascular disease due to MI risk, and in those with active thromboembolic disease 2

Tranexamic Acid (Alternative First-Line)

• Antifibrinolytic therapy significantly reduces menstrual blood loss (20-60% reduction) 1, 5, 7
• Particularly effective for women with fibroids or other structural causes 1
• Contraindication: Active thromboembolic disease or history/intrinsic risk for thrombosis 4
• Also avoid in cardiovascular disease patients due to thrombosis risk 2

Second-Line Hormonal Options

If NSAIDs or tranexamic acid fail after 2-3 cycles or are contraindicated:

Levonorgestrel-Releasing IUD (LNG-IUD)

• Most effective long-term treatment, reducing menstrual blood loss by 71-95% 1
• Provides contraception and is comparable in efficacy to endometrial ablation or hysterectomy 1, 7
• Particularly useful for women desiring long-term contraception 1

Combined Hormonal Contraceptives

• Effective for reducing menstrual blood loss when hormonal options are appropriate 1
• Extended or continuous cycles minimize hormone-free intervals and are particularly appropriate for severe cases 6
• Monophasic formulations with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are recommended 6

Cyclic Oral Progestins

• Reduce bleeding by approximately 87%, though may cause irregular bleeding patterns 1
• Note: Cyclic progestins do not significantly reduce bleeding in ovulating women 7

Special Considerations

Bleeding Disorders

• Up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder (most commonly von Willebrand disease) 1, 8, 9
• In women with known bleeding disorders, desmopressin (300 μg/day intranasal) for the first 5 days of menses can significantly reduce blood loss 4, 8
• Iron supplementation is paramount in all cases of prolonged bleeding 8

When to Refer to Gynecology

Refer when: 2

• Failed medical management after appropriate trial
• Endometrial sampling shows hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm on ultrasound
• Persistent bleeding despite treatment with unidentified cause

Treatment Algorithm Summary

1. Rule out pregnancy and assess stability 2
2. Exclude structural/pathological causes with ultrasound and physical exam 2
3. Start NSAIDs (5-7 days) or tranexamic acid 1, 6
4. If ineffective after 2-3 cycles: Consider LNG-IUD or combined hormonal contraceptives 1, 6
5. If unacceptable to patient or continued failure: Refer to gynecology for surgical options 2

Enhanced counseling about expected bleeding patterns and reassurance improves treatment adherence and reduces discontinuation 1