What medication is recommended for a 40-year-old woman experiencing heavy vaginal bleeding?

Medical Management of Heavy Vaginal Bleeding in a 40-Year-Old Woman

Start with monophasic combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate as first-line treatment after ruling out pregnancy, infection, and structural pathology. 1

Initial Evaluation Before Treatment

Before initiating any medication, you must exclude:

• Pregnancy (obtain hCG test) 2
• Sexually transmitted infections (particularly gonorrhea and chlamydia in reproductive-aged women) 1
• Structural lesions (perform pelvic examination and transvaginal ultrasound to identify fibroids, polyps, or other pathology) 1, 2
• Cervical pathology (speculum examination and Pap smear per guidelines) 2

First-Line Medical Treatment

Combined oral contraceptives (COCs) are the recommended initial therapy:

• Use a monophasic formulation with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate 1, 3
• COCs reduce menstrual blood loss by inducing regular shedding of a thinner endometrium 1
• Additional benefits include decreased cramping, improvement in acne, and reduced risk of endometrial and ovarian cancers 1, 3

Before prescribing COCs, assess thrombotic risk factors:

• COCs increase venous thromboembolism risk 3-4 fold 1, 3
• Monitor blood pressure at follow-up visits 1, 3

Management of Persistent Bleeding on COCs

If bleeding continues despite COC therapy:

• Add NSAIDs for 5-7 days during bleeding episodes as first-line adjunctive therapy 1, 4
• NSAIDs (such as mefenamic acid, indomethacin, or diclofenac) reduce menstrual blood loss acutely 5, 6
• For extended/continuous COC regimens, consider a hormone-free interval of 3-4 consecutive days for heavy bleeding, but not during the first 21 days of use and not more than once per month 1

Re-evaluate for underlying pathology if bleeding persists beyond 3-6 months:

• Check for IUD displacement (if applicable), STDs, pregnancy, or new pathologic uterine conditions such as polyps or fibroids 1, 4

Alternative First-Line Options

Levonorgestrel intrauterine system (LNG-IUD):

• Results in 71-95% reduction in menstrual blood loss, comparable to endometrial ablation 3
• Most effective medical treatment for heavy menstrual bleeding 2, 7
• Particularly useful if contraception is also desired 6, 8

Tranexamic acid:

• Reduces menstrual blood loss by 20-60% 8, 9
• Appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 2
• FDA warning: Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 5

Second-Line Options

If first-line treatments fail or are contraindicated:

• Depot medroxyprogesterone acetate (DMPA) 150 mg intramuscularly every 12 weeks 3
• For heavy bleeding with DMPA, add NSAIDs for 5-7 days 3
• Note: Cyclic oral progestogens reduce menstrual blood loss by approximately 87% but are less effective than other options 3, 7

Counseling and Follow-Up

Provide anticipatory guidance:

• Unscheduled spotting or bleeding is common during the first 3-6 months of hormonal therapy and generally not harmful 5, 1
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 5

Follow-up approach:

• No routine follow-up visit is required 1, 3
• Patients should return for side effects or concerns 1, 4
• Assess satisfaction with the method and any health status changes at follow-up 1, 4

When to Consider Surgical Options

If medical therapies fail and the patient does not desire future pregnancy:

• Consider endometrial ablation (second-generation techniques preferred) or hysterectomy as definitive treatment 6, 2
• Conservative surgical treatment has greater long-term efficacy than oral medical treatment for idiopathic heavy bleeding 2