What treatment options are available for a patient with a prolonged menstrual cycle lasting 14 days?

Treatment of Prolonged Menstrual Bleeding (14 Days)

Start NSAIDs (mefenamic acid, ibuprofen, or naproxen—NOT aspirin) for 5-7 days during bleeding episodes as first-line therapy, while simultaneously ruling out pregnancy, structural pathology (fibroids, polyps), and systemic causes (thyroid dysfunction, coagulopathy). 1, 2

Immediate Evaluation Required

Before initiating treatment, assess for:

• Pregnancy status: Mandatory β-hCG test in all reproductive-age women 3, 4
• Structural causes: Transvaginal ultrasound to identify fibroids, polyps, adenomyosis, or endometrial pathology 4
• Coagulopathy: Personal or family history of bleeding (epistaxis, easy bruising, dental bleeding) suggests von Willebrand disease or other bleeding disorders—present in up to 20% of women with heavy menstrual bleeding 5, 6
• Thyroid dysfunction: Check TSH and prolactin for ovulatory dysfunction 4
• Medication review: Anticoagulants or antiplatelet therapy significantly contribute to prolonged bleeding 3

First-Line Medical Treatment Algorithm

NSAIDs (5-7 days during bleeding)

• Reduce menstrual blood loss by 20-60% 1, 2
• Use mefenamic acid, ibuprofen, naproxen, or diclofenac 1
• Avoid aspirin—it paradoxically increases bleeding 1, 4
• Contraindication: Women with cardiovascular disease (increased MI and thrombosis risk) 3

If NSAIDs Fail or Are Contraindicated

Tranexamic acid is the most effective acute treatment:

• Reduces bleeding by 40-60% 2, 3, 4
• Absolute contraindication: Active thromboembolism or history of thrombosis 2, 3, 4
• More expensive than NSAIDs but highly effective 1

Second-Line Hormonal Therapy (If Bleeding Persists After 7 Days)

For Women Not Using Contraception

• Combined oral contraceptives (COCs) or estrogen for 10-20 days during bleeding episodes 1, 2
• Extended or continuous COC cycles are particularly effective for anovulatory bleeding and can reduce hormone-free intervals 1

For Women Using Copper IUD

• NSAIDs remain first-line (5-7 days) 1, 2
• Important caveat: Bleeding in the first 3-6 months of Cu-IUD use is common, generally not harmful, and decreases with continued use 1, 2
• If bleeding develops after months of normal use, evaluate for IUD displacement, infection, pregnancy, or new uterine pathology 1, 2

For Women Using DMPA (Depo-Provera)

• NSAIDs for 5-7 days for unscheduled spotting or light bleeding 1
• For heavy or prolonged bleeding: NSAIDs or low-dose COCs/estrogen for 10-20 days (if medically eligible) 1

Most Effective Long-Term Solution

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment for prolonged menstrual bleeding:

• Reduces menstrual blood loss by 71-95% 2, 3, 4
• Efficacy comparable to endometrial ablation or hysterectomy 4
• Particularly beneficial for women on anticoagulation or antiplatelet therapy 4
• Can be used through menopause in perimenopausal women 2, 3

Treatment Algorithm Summary

1. Days 1-7: NSAIDs (5-7 days) + rule out pregnancy/pathology 1, 2
2. If bleeding continues beyond 7 days: Add COCs or estrogen for 10-20 days 1, 2
3. If bleeding persists after 3 months: Consider LNG-IUS or tranexamic acid 2, 3, 4
4. If medical management fails: Counsel on alternative methods; consider endometrial ablation 3

Critical Pitfalls to Avoid

• Never use aspirin—it worsens bleeding 1, 4
• Do not prescribe tranexamic acid to women with cardiovascular disease or thrombosis history—absolute contraindication 2, 3, 4
• Do not dismiss bleeding in Cu-IUD users during first 3-6 months—this is expected and not harmful, but new-onset bleeding after months of use requires evaluation 1, 2
• Assess cardiovascular risk before prescribing COCs in perimenopausal women—thrombotic risk increases with age 2, 3

When to Refer to Gynecology

Urgent referral indicated for:

• Failure of medical treatment after 3 months 4
• Endometrial thickness ≥4 mm in postmenopausal women 4
• Endometrial biopsy showing hyperplasia or malignancy 4
• Persistent hemodynamic instability 4

When to Refer to Hematology

• Personal or family history of bleeding disorders (epistaxis, easy bruising, dental bleeding) 4, 5
• Refractory bleeding despite optimal medical therapy 4
• Suspected von Willebrand disease or other coagulopathy 5, 6