How to manage acute prolonged menses (abnormal uterine bleeding)?

Management of Acute Prolonged Menses

For acute prolonged menstrual bleeding, start combined oral contraceptives containing 30-35 μg ethinyl estradiol (with levonorgestrel or norgestimate) as first-line treatment after ruling out pregnancy, infection, and structural lesions. 1

Immediate Assessment

Rule out life-threatening bleeding first:

• Urgent evaluation is warranted if bleeding saturates a large pad or tampon hourly for at least 4 hours or if hemodynamic instability is present 2
• All reproductive-age women must have a pregnancy test before treatment 2, 1
• Exclude sexually transmitted infections, particularly in reproductive-aged women 1
• Assess for structural pathology including uterine fibroids, polyps, adenomyosis 3

First-Line Medical Treatment

Combined oral contraceptives (COCs) are the gold standard for acute prolonged bleeding:

• Use monophasic formulations with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate 1
• These work by inducing regular shedding of a thinner endometrium, effectively reducing menstrual blood loss 1
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 1
• Screen for thrombotic risk factors before prescribing, as COCs increase venous thromboembolism risk three to fourfold 1

Management of Persistent Bleeding

If bleeding continues despite COC therapy:

• Add NSAIDs for 5-7 days during bleeding episodes to acutely reduce blood flow 1, 3
• Consider hormonal treatment for 10-20 days if medically eligible 1
• For extended/continuous COC regimens with heavy bleeding, allow a hormone-free interval of 3-4 consecutive days, but avoid this during the first 21 days or more than once per month 1
• Reassure patients that unscheduled bleeding is common during the first 3-6 months and generally not harmful 1

Alternative Medical Options

If first-line treatment fails or is contraindicated:

Progestin-Based Treatments

• Levonorgestrel-releasing intrauterine device (LNG-IUS 20 μg/d) is the most effective progesterone-based option, achieving 71-95% reduction in menstrual blood loss 4
• Cyclic oral progestin reduces bleeding by 87% and typically results in eventual reduction to light bleeding only 4
• For hemodynamically unstable women when bleeding is not controlled, high-dose oral or injectable progestin-only medications may be considered short-term 4
• Note: Injectable medroxyprogesterone acetate is NOT recommended for acute bleeding or dysfunctional uterine bleeding due to prolonged action and unpredictable withdrawal bleeding timing 5

Non-Hormonal Options

• Tranexamic acid reduces menstrual blood loss by approximately 80 mL/cycle 3
• Tranexamic acid is contraindicated in women with active thromboembolic disease or history/risk of thrombosis 3
• NSAIDs provide significant reductions in menstrual blood loss when used for 5-7 days during bleeding 3

Special Populations

Women with cardiovascular disease or spontaneous coronary artery dissection:

• Hormonal therapy is relatively contraindicated and requires careful clinical judgment 2, 4
• NSAIDs and tranexamic acid should generally be avoided given their association with MI and thrombosis 2
• If hormonal treatment is necessary, consider LNG-IUS as it works primarily at the endometrial level with minimal systemic absorption 2, 4

When to Escalate

Consider surgical options if:

• Medical management fails and bleeding is unacceptable to the patient 1
• Clear structural causes are identified 3
• Patient no longer desires future fertility and has associated pelvic pathology 3

Surgical options include:

• Endometrial ablation (may be less effective with fibroids or adenomyosis) 3
• Uterine artery embolization for fibroid-associated bleeding 3
• Hysterectomy as the most definitive treatment 3

Follow-Up Strategy

• No routine follow-up is required for patients on COCs, but they should return for side effects or concerns 1
• Assess satisfaction with the method and any health status changes at follow-up visits 1
• Monitor blood pressure at follow-up visits for women on COCs 1
• Re-evaluate for underlying gynecological problems if bleeding persists beyond 3-6 months 1
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 4

Critical Pitfalls to Avoid

• Never start hormonal treatment without first ruling out pregnancy 2, 1
• Do not use injectable progestins for acute bleeding management due to unpredictable withdrawal bleeding 5
• Avoid NSAIDs and tranexamic acid in women with cardiovascular disease or thrombotic risk 2, 3
• Do not dismiss persistent bleeding beyond 6 months—re-evaluate for structural pathology 1
• In women 35 years or older with recurrent anovulation, or younger women with risk factors for endometrial cancer, perform endometrial biopsy before treatment 6