What are the first line treatment options for heavy menstrual bleeding?

First-Line Treatment Options for Heavy Menstrual Bleeding

For women not seeking immediate pregnancy, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment, reducing menstrual blood loss by 71-95%, followed by tranexamic acid and NSAIDs as alternative first-line options. 1, 2, 3

Most Effective First-Line Treatment: LNG-IUD

• The LNG-IUD (20 μg/day) achieves the greatest reduction in menstrual blood loss of all medical treatments, decreasing bleeding by 71-95%. 1, 2, 3
• Over time, many women experience only light menstrual bleeding or amenorrhea with the LNG-IUD, providing sustained symptom relief. 4, 2
• The LNG-IUD provides dual benefit by simultaneously treating heavy bleeding and providing contraception. 1
• This device can be used through menopause in perimenopausal women. 2

Alternative First-Line Medical Options (When LNG-IUD Not Appropriate)

NSAIDs (Preferred for Women Seeking Pregnancy or Short-Term Treatment)

• NSAIDs are the recommended first-line pharmacologic treatment when the LNG-IUD is not suitable, prescribed for 5-7 days during menstruation only. 4, 2
• Multiple NSAIDs demonstrate statistically significant reductions in menstrual blood loss, including mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium. 4
• NSAIDs reduce menstrual blood loss by approximately 40 mL per cycle compared to placebo. 3
• Critical contraindication: NSAIDs must be avoided in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis. 5, 2
• Avoid aspirin—it does not reduce bleeding and may actually increase blood loss in women with lower baseline menstrual blood loss. 4, 2

Tranexamic Acid (Non-Hormonal Alternative)

• Tranexamic acid is a non-hormonal alternative that reduces menstrual blood loss by approximately 80 mL per cycle. 4, 2
• Tranexamic acid ranks as the second most effective first-line treatment after the LNG-IUD. 3
• Absolute contraindication: tranexamic acid is contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease. 4, 5, 2

Combined Hormonal Contraceptives

• Combined oral contraceptives (COC) or combined vaginal ring (CVR) can reduce menstrual blood loss and provide contraception. 4, 3
• These rank as third-line medical options after LNG-IUD and tranexamic acid. 3

Long-Cycle Oral Progestogens

• Long-cycle oral progestogens (≥3 weeks per cycle) reduce menstrual blood loss by approximately 87% and may result in irregular bleeding patterns. 1, 3
• Cyclic oral progestin treatment often reduces menses to light bleeding. 1

Essential Initial Assessment Before Treatment

• Rule out pregnancy in all reproductive-age women with abnormal bleeding—perform β-hCG testing. 1, 5, 2
• Assess for hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss requiring urgent evaluation. 1, 5
• Urgent evaluation is warranted for bleeding that saturates a large pad or tampon hourly for at least 4 hours. 1, 5
• Evaluate for structural causes including fibroids, polyps, adenomyosis, endometrial pathology, or malignancy using combined transabdominal and transvaginal ultrasound with Doppler as first-line imaging. 5
• Screen for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder. 2, 6
• In patients on antiplatelet therapy, reassess the indication for ongoing antiplatelet therapy and consider discontinuation if appropriate. 1, 5

Treatment Algorithm

1. First choice (non-pregnancy seeking): LNG-IUD for maximum bleeding reduction (71-95% reduction) 1, 2, 3

2. Alternative first-line options:

   • NSAIDs (5-7 days during menses) if cardiovascular disease is absent and pregnancy is desired 4, 2
   • Tranexamic acid if no thrombotic risk factors and hormonal contraception is undesired 4, 2
   • Combined hormonal contraceptives if contraception is also desired 4, 3
   • Long-cycle oral progestogens if other options are unsuitable 1, 3

3. If first-line medical treatment fails: Consider referral for second-line treatments including endometrial ablation or hysterectomy 1, 5

Critical Counseling Points

• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities with certain treatments (especially LNG-IUD) are generally not harmful during the first 3-6 months can improve treatment adherence and reduce discontinuation. 4, 2
• Unscheduled spotting or light bleeding is expected during the first 3-6 months of LNG-IUD use but decreases with continued use. 4

4, 1, 5, 2, 3