Treatment of Heavy Menstrual Bleeding with Quarter-Size Clots
Start with NSAIDs (naproxen, mefenamic acid, or ibuprofen) for 5-7 days during active bleeding as first-line therapy, then transition to a levonorgestrel-releasing intrauterine device (LNG-IUD) for long-term management, which reduces menstrual blood loss by 71-95%. 1, 2
Immediate First-Line Treatment
NSAIDs are the recommended initial pharmacologic treatment for heavy menstrual bleeding with clots, prescribed specifically during the 5-7 days of active menstruation only. 3, 1, 2 Multiple NSAIDs have demonstrated statistically significant reductions in menstrual blood loss:
- Naproxen (preferred agent) 1, 2
- Mefenamic acid 2
- Ibuprofen 2
- Avoid aspirin - it does not reduce bleeding and may actually increase blood loss 2
Critical NSAID Contraindications
Do not prescribe NSAIDs if the patient has:
- Cardiovascular disease (increased risk of myocardial infarction and thrombosis) 2
- History of spontaneous coronary artery dissection 4
- Active peptic ulcer disease 2
Screen for cardiovascular risk factors before initiating NSAID therapy. 2
Long-Term Management: LNG-IUD as Most Effective Option
The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95% and should be offered as the definitive long-term solution. 1, 2
LNG-IUD Benefits:
- Provides contraception while treating bleeding 1
- Over time, many women experience only light menstrual bleeding or amenorrhea 2
- Can be used through menopause in perimenopausal women 2
- Effectiveness comparable to endometrial ablation or hysterectomy 5
Alternative Second-Line Options
Tranexamic Acid (Non-Hormonal)
Tranexamic acid reduces menstrual blood loss by approximately 80 mL per cycle and is an effective non-hormonal alternative. 1, 2
Absolute contraindications for tranexamic acid:
- Active thromboembolic disease 2, 6
- History of thrombosis or cardiovascular disease 2, 6
- Active intravascular clotting 6
- Subarachnoid hemorrhage 6
Combined Hormonal Contraceptives
Combined oral contraceptives or transvaginal hormonal contraceptives are effective for reducing menstrual blood loss when hormonal options are appropriate. 1, 7
Cyclic Oral Progestins
Cyclic oral progestins reduce bleeding by approximately 87%, though may result in irregular bleeding patterns initially. 1, 4
Essential Initial Assessment
Before initiating treatment, evaluate:
- Rule out pregnancy in all reproductive-age women with abnormal bleeding 1, 4, 2
- Assess hemodynamic stability - bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation 4
- Check for anemia with hemoglobin/hematocrit 8
- Evaluate for structural causes including fibroids, polyps, adenomyosis, or endometrial pathology 2
- Screen for coagulopathies - up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1, 2, 8
Treatment Algorithm
Immediate symptom control: NSAIDs for 5-7 days during active bleeding (if no cardiovascular contraindications) 3, 1, 2
Long-term management: LNG-IUD insertion for sustained reduction in menstrual blood loss 1, 2
If LNG-IUD declined or contraindicated: Tranexamic acid (if no thrombotic risk) or combined hormonal contraceptives 1, 2
If medical management fails: Consider endometrial ablation or hysterectomy for refractory cases 4, 5
Critical Counseling Points
Enhanced counseling about expected bleeding patterns improves treatment adherence. 3, 2 Specifically:
- NSAIDs work immediately but only during active use 2
- LNG-IUD may cause irregular bleeding for the first 3-6 months before improvement 3
- Many women eventually experience amenorrhea with LNG-IUD, which is safe and expected 2
Special Populations
For women on anticoagulation: 70% experience heavy menstrual bleeding; reassess the indication for ongoing antiplatelet therapy and consider LNG-IUD as it provides local rather than systemic hormonal effects. 4, 9
For women with history of thrombosis: Avoid tranexamic acid and combined hormonal contraceptives unless patient is therapeutically anticoagulated; LNG-IUD is preferred. 6, 9