How to manage menorrhagia (heavy menstrual bleeding) lasting two weeks?

Management of Heavy Menstrual Bleeding Lasting Two Weeks

For heavy menstrual bleeding lasting two weeks, start with NSAIDs (mefenamic acid or naproxen) for 5-7 days during active bleeding, but if this fails or for long-term management, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective treatment, reducing menstrual blood loss by 71-95%. 1, 2

Immediate Assessment Required

Before initiating treatment, you must rule out three critical conditions:

• Pregnancy test in all reproductive-age women—this is mandatory 1, 2
• Structural causes including fibroids, polyps, adenomyosis, or endometrial malignancy through pelvic examination and transvaginal ultrasound 1, 2
• Coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 1
• Hemodynamic stability—bleeding saturating a large pad hourly for 4+ hours requires urgent evaluation 3

First-Line Treatment Algorithm

Option 1: NSAIDs (Immediate Short-Term Control)

NSAIDs are the recommended first-line pharmacologic treatment for immediate symptom control 1, 2:

• Use mefenamic acid, naproxen, indomethacin, or diclofenac for 5-7 days during menstruation only 1
• These reduce menstrual blood loss by 20-60% 4
• Never use aspirin—it does not reduce bleeding and may actually increase blood loss 1

Critical contraindication: Absolutely avoid NSAIDs in women with cardiovascular disease, as they increase risk of myocardial infarction and thrombosis 1, 2. Screen for cardiovascular risk factors before prescribing 1.

Option 2: LNG-IUD (Most Effective Long-Term Treatment)

The levonorgestrel-releasing intrauterine device is the single most effective medical treatment available 1, 3, 2:

• Reduces menstrual blood loss by 71-95%—superior to all other medical options 1, 3, 2, 5
• Over time, many women experience only light bleeding or complete amenorrhea 1
• Can be used through menopause in perimenopausal women 1, 2
• Effectiveness is comparable to endometrial ablation or hysterectomy 4

Second-Line Treatment Options

If NSAIDs fail and LNG-IUD is not acceptable or feasible:

Tranexamic Acid (Non-Hormonal Alternative)

• Reduces menstrual blood loss by approximately 80 mL per cycle 1
• More effective than NSAIDs but less effective than LNG-IUD 6
• Absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 1, 2

Combined Hormonal Contraceptives

• Second-choice hormonal option after LNG-IUD 5
• Requires careful cardiovascular risk assessment, especially in perimenopausal women 2

Cyclic Oral Progestogens

• Reduces bleeding by approximately 87% when given for ≥3 weeks per cycle 3, 5
• Important caveat: Short-course progestogens (≤14 days per cycle) are less effective and may be insufficient 5

Common Pitfalls to Avoid

Do not use short-course luteal phase progestogens (10-14 days)—these do not significantly reduce menstrual bleeding in ovulating women and are less effective than other options 5, 4.

Enhanced counseling about expected bleeding patterns improves treatment adherence—warn patients that irregular bleeding may occur initially with hormonal treatments but often improves over time 1.

When Medical Management Fails

If bleeding persists despite optimal medical therapy 2:

• Counsel on alternative contraceptive methods and offer different medical options 7, 2
• Consider endometrial ablation as a conservative surgical option 3, 2
• Reserve hysterectomy for refractory cases after less invasive procedures have been attempted 3

Special Considerations for Two-Week Duration

Bleeding lasting two weeks suggests either very heavy flow or prolonged duration beyond normal menstruation. This warrants:

• More aggressive initial evaluation for structural causes and coagulopathies 1, 2
• Consider starting with combination therapy: NSAIDs for immediate control while simultaneously placing LNG-IUD for long-term management 1, 2
• If patient is on antiplatelet therapy, reassess the indication for ongoing treatment as this may worsen menstrual bleeding 3