What are the treatment options for a patient with heavy menstrual bleeding?

Treatment of Heavy Menstrual Bleeding

NSAIDs are the recommended first-line pharmacologic treatment for heavy menstrual bleeding, prescribed for 5-7 days during menstruation only. 1

First-Line Treatment: NSAIDs

Use NSAIDs as initial therapy for 5-7 days during active bleeding days only. 1 Multiple agents have demonstrated statistically significant reductions in menstrual blood loss, including:

• Mefenamic acid 2, 1
• Naproxen 1, 3
• Indomethacin 2
• Flufenamic acid 2
• Diclofenac sodium 2

Avoid aspirin—it does not reduce bleeding and may actually increase blood loss. 1

Critical NSAID Contraindications

Screen for cardiovascular disease before prescribing NSAIDs, as they increase risk of myocardial infarction and thrombosis. 1 NSAIDs must be avoided in women with:

• Cardiovascular disease 1
• History of spontaneous coronary artery dissection 4

Most Effective Treatment: Levonorgestrel-Releasing IUD

The LNG-IUD is the most effective medical treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95%. 1, 3 This represents superior efficacy compared to all other medical options. 5

• Over time, many women experience only light menstrual bleeding or amenorrhea with the LNG-IUD 1
• Can be used through menopause in perimenopausal women 1
• Provides contraception while treating heavy bleeding 3
• Effective even in women with fibroids and adenomyosis 2, 5

Consider LNG-IUD as first-line for women desiring contraception or long-term solution. 3

Alternative Non-Hormonal Option: Tranexamic Acid

Tranexamic acid reduces menstrual blood loss by approximately 80 mL per cycle. 1 This is a non-hormonal alternative for women who cannot or prefer not to use hormonal treatments. 3

Absolute Contraindications for Tranexamic Acid

Tranexamic acid is absolutely contraindicated in women with: 1, 6

• Active thromboembolic disease 1, 6
• History of thrombosis 1
• Cardiovascular disease 1
• Active intravascular clotting 6
• Subarachnoid hemorrhage 6

Avoid concomitant use with pro-thrombotic medications including Factor IX concentrates, anti-inhibitor coagulant concentrates, and hormonal contraceptives. 6

Hormonal Alternatives

Cyclic oral progestins reduce bleeding by approximately 87%, though may result in irregular bleeding patterns. 3 Combined hormonal contraceptives are effective for reducing menstrual blood loss when hormonal options are appropriate. 3

Essential Initial Assessment

Before initiating treatment, perform the following evaluations:

• Rule out pregnancy in all reproductive-age women 1, 4, 3
• Assess for structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 1
• Evaluate for coagulopathies if clinically indicated—up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1, 3
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss 4
• Test for anemia and check serum ferritin 7, 8

Red Flags Requiring Urgent Evaluation

Bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation. 4

Treatment Algorithm

1. For women desiring contraception or long-term solution: Start with LNG-IUD 3
2. For short-term symptom management or women who cannot use hormonal methods: Use NSAIDs for 5-7 days during bleeding 1, 3
3. For non-hormonal option in women with cardiovascular contraindications to NSAIDs: Consider tranexamic acid (if no thrombotic risk factors) 3
4. If first-line treatments fail: Consider cyclic oral progestins or combined hormonal contraceptives 3

Important Counseling Points

Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities with certain treatments are generally not harmful improves treatment adherence. 2, 1, 3 This is particularly important for:

• Cu-IUD users who may experience unscheduled spotting or heavy bleeding during the first 3-6 months 2
• Women starting any new hormonal treatment 3

Common Pitfalls to Avoid

• Do not use aspirin for heavy menstrual bleeding—it may worsen blood loss 1
• Do not prescribe NSAIDs continuously—limit to 5-7 days during active bleeding only 1
• Do not overlook cardiovascular screening before NSAID therapy 1
• Do not use tranexamic acid in women with any history of thrombosis or cardiovascular disease 1, 6
• Do not assume bleeding is benign—always evaluate for structural causes and bleeding disorders, especially in adolescents 1, 7, 8

Special Populations

Patients on antiplatelet therapy may experience worsened menstrual bleeding—reassess the indication for ongoing antiplatelet therapy. 4

For adolescents with heavy menstrual bleeding, maintain high suspicion for underlying bleeding disorders and coordinate with hematology for evaluation. 8