What is the best management approach for a 50-year-old female with menorrhagia (heavy menstrual bleeding) and anemia, presenting with dizziness, and a history of stroke on anticoagulation therapy and hepatitis C?

Management of Heavy Menstrual Bleeding with Anemia in a Patient on Anticoagulation with History of Stroke and Hepatitis C

For this 50-year-old woman with menorrhagia causing anemia and dizziness while on anticoagulation for stroke history, initiate tranexamic acid 1300 mg orally three times daily during menstruation (days 1-5 only) combined with a levonorgestrel intrauterine system (LNG-IUS) for long-term control, while continuing anticoagulation without interruption. 1, 2

Immediate Assessment and Stabilization

• Assess hemodynamic stability immediately: Check for orthostatic hypotension, tachycardia, or signs of hemodynamic compromise that would indicate major bleeding requiring urgent intervention. 3, 4

• Obtain hemoglobin level urgently: Transfuse packed red blood cells if hemoglobin is <7 g/dL (or <8 g/dL if coronary artery disease is present) to address symptomatic anemia causing dizziness. 4

• Verify pregnancy status: Perform β-hCG testing as mandatory in all women of reproductive age with abnormal uterine bleeding, even at age 50. 1

• Evaluate hepatic function: Given hepatitis C history, obtain liver function tests and coagulation studies (PT/INR, aPTT) to assess for hepatic synthetic dysfunction that could contribute to bleeding. 3

Anticoagulation Management - Critical Decision Point

DO NOT discontinue or reduce anticoagulation therapy in this patient with history of stroke, as the thrombotic risk far outweighs bleeding risk once hemostasis is achieved with medical therapy. 3, 2

• Continue full-dose anticoagulation while initiating hemostatic therapy for menorrhagia, as abbreviating anticoagulation or skipping doses increases recurrent venous thromboembolism risk by fivefold. 2

• Consider switching anticoagulants if currently on rivaroxaban: Apixaban or dabigatran are associated with lower rates of heavy menstrual bleeding (affecting ~70% of women on oral anticoagulants overall, but less with apixaban/dabigatran than rivaroxaban). 2

• Avoid platelet transfusions: Do not transfuse platelets even if bleeding, as this is associated with worse outcomes and higher mortality. 4

First-Line Medical Therapy

Tranexamic Acid (Immediate Control)

Prescribe tranexamic acid 1300 mg orally three times daily (total 3.9 g/day) for 4-5 days starting from day 1 of menstruation only. 1, 5, 6

• Tranexamic acid reduces menstrual blood loss by 40-60% and is significantly more effective than placebo, NSAIDs, or oral progestogens. 1, 6, 7

• Critical safety consideration: Despite theoretical thrombotic concerns, long-term studies show the incidence of thrombosis in women treated with tranexamic acid is comparable to spontaneous frequency in untreated women. 6, 7

• Specific contraindication check: Active intravascular clotting is an absolute contraindication; however, history of stroke on stable anticoagulation is NOT a contraindication to tranexamic acid use. 5

• Hepatitis C consideration: Dose adjustment is required only if hepatic dysfunction has caused renal impairment (serum creatinine >1.36 mg/dL); otherwise, standard dosing applies. 5

• Monitor for dizziness: Tranexamic acid may worsen dizziness; advise patient to avoid driving until effects are known, particularly important given her presenting symptom. 5

Levonorgestrel Intrauterine System (Long-Term Control)

Insert LNG-IUS as the definitive long-term treatment, as it reduces menstrual blood loss by 71-95% and is more effective than tranexamic acid alone. 1, 8, 6

• The LNG-IUS is particularly useful in patients on anticoagulation and is the most effective medical treatment for heavy menstrual bleeding. 1

• Efficacy is comparable to endometrial ablation or hysterectomy but avoids surgical risks in a patient on anticoagulation. 1

• Can be used concurrently with anticoagulation without increasing thrombotic risk, unlike combined oral contraceptives. 1, 2

Alternative Hormonal Options (If LNG-IUS Declined or Contraindicated)

• Subdermal progestin implant: Can result in decreased blood loss and amenorrhea in some cases while continuing anticoagulation. 2

• Combined oral contraceptive pills (COCPs): Highly effective for decreasing menstrual blood loss and can be used while continuing anticoagulation, though less effective than LNG-IUS. 8, 9, 2

• Depot medroxyprogesterone acetate (DMPA): Alternative if LNG-IUS cannot be tolerated. 8

Therapies to AVOID

DO NOT use NSAIDs (except as last resort): While NSAIDs reduce blood loss by 20-60%, they are significantly less effective than tranexamic acid and may increase bleeding risk in anticoagulated patients. 1, 6

NEVER use aspirin: Aspirin paradoxically increases bleeding and is contraindicated. 1

Avoid oral luteal-phase progestogens: These are significantly less effective than tranexamic acid (mean blood loss reduction difference of -111.0 mL favoring tranexamic acid). 7

Iron Repletion and Anemia Management

• Evaluate for iron deficiency: Check ferritin, iron studies, and assess for iron deficiency anemia as a consequence of chronic blood loss. 10, 2

• Initiate oral iron supplementation: Prescribe ferrous sulfate 325 mg orally 2-3 times daily if iron deficiency is confirmed. 4

• Consider intravenous iron: If oral iron is not tolerated or absorption is impaired due to hepatitis C-related gastrointestinal issues. 4

Structural Evaluation

• Perform transvaginal ultrasound with Doppler: First-line imaging to identify structural causes including polyps, adenomyosis, leiomyomas, or endometrial hyperplasia/malignancy. 1

• Endometrial biopsy if indicated: Perform if endometrial thickness is abnormal, patient is at risk for endometrial hyperplasia, or if bleeding persists despite medical therapy. 1

Monitoring and Follow-Up

• Reassess at 3 months: Evaluate efficacy of tranexamic acid and LNG-IUS; failure of medical treatment after 3 months warrants urgent gynecology referral. 1

• Monitor hemoglobin monthly initially: Ensure stabilization and no ongoing occult bleeding once therapy is initiated. 4

• Screen for bleeding disorders: Given 7-year history of heavy menstrual bleeding, consider referral to hematology to evaluate for hereditary bleeding disorders (von Willebrand disease affects ~90% of women with underlying bleeding disorders). 10

Surgical Referral Criteria

Refer urgently to gynecology if:

• Failure of medical treatment after 3 months 1
• Endometrial biopsy showing hyperplasia or malignancy 1
• Persistent hemodynamic instability despite medical therapy 1
• Patient preference for definitive surgical management 1

Critical Pitfalls to Avoid

• DO NOT stop anticoagulation: The stroke recurrence risk outweighs bleeding risk once hemostatic therapy is initiated. 3, 2

• DO NOT withhold tranexamic acid due to anticoagulation: There is no evidence of increased thrombotic events when tranexamic acid is used appropriately in anticoagulated patients. 6, 7

• DO NOT use liberal transfusion thresholds: Restrictive strategy (hemoglobin 7-8 g/dL) improves survival compared to liberal transfusion. 4

• DO NOT delay LNG-IUS insertion: This is the most effective long-term therapy and should be offered early rather than relying solely on tranexamic acid. 1, 2