What are the medication guidelines for managing heavy menstrual bleeding?

Medical Management of Heavy Menstrual Bleeding

NSAIDs are the recommended first-line pharmacologic treatment for heavy menstrual bleeding, prescribed for 5-7 days during menstruation only, with the levonorgestrel-releasing intrauterine device (LNG-IUD) serving as the most effective second-line medical therapy when NSAIDs fail or are contraindicated. 1

First-Line Pharmacologic Treatment

NSAIDs (Preferred Initial Therapy)

• Multiple NSAIDs demonstrate statistically significant reductions in menstrual blood loss, including mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium. 1
• Treatment duration must be strictly limited to 5-7 days during active bleeding days only—not throughout the entire cycle. 1
• Aspirin must be avoided as it does not reduce bleeding and may actually increase blood loss in women with lower baseline menstrual blood loss. 1

Critical NSAID Contraindications

• NSAIDs are absolutely contraindicated in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis. 1
• Screen all patients for cardiovascular risk factors before initiating NSAID therapy. 1
• Avoid NSAIDs in patients with history of spontaneous coronary artery dissection. 2

Second-Line Medical Treatment

Levonorgestrel-Releasing Intrauterine Device (Most Effective)

• The LNG-IUD reduces menstrual blood loss by 71-95%, making it the most effective medical treatment for heavy menstrual bleeding. 1, 2
• Over time, many women experience only light menstrual bleeding or complete amenorrhea with the LNG-IUD. 1
• The LNG-IUD can be used through menopause in perimenopausal women. 1
• The LNG-IUD is more effective at reducing menstrual blood loss than tranexamic acid. 3

Tranexamic Acid (Non-Hormonal Alternative)

• Tranexamic acid reduces menstrual blood loss by approximately 80 mL per cycle (26-60% reduction), making it significantly more effective than placebo, NSAIDs, or oral cyclical progestins. 1, 3
• Recommended oral dosage is 3.9-4 g/day for 4-5 days starting from the first day of menstruation. 3
• Tranexamic acid is absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease. 1
• Particularly useful in women who desire immediate pregnancy or for whom hormonal treatment is inappropriate. 4
• Adverse effects are few and mainly mild, with no evidence of increased thrombotic events in appropriate candidates. 3

Combined Oral Contraceptives

• Combined oral contraceptives (ethinyl estradiol 30 μg and norgestrel 0.3 mg) are equally effective as tranexamic acid in reducing mean blood loss. 5
• Efficacy is significantly higher in younger age groups and particularly effective in patients with leiomyomas. 5

Cyclic Oral Progestin

• Cyclic oral progestin treatment reduces bleeding by approximately 87% but may result in irregular bleeding patterns. 2
• Often reduces menses to light bleeding over time. 2

Additional Medical Options for Specific Scenarios

For Uterine Fibroids with Heavy Bleeding

• First-line medical management includes NSAIDs and estrogen-progestin oral contraceptive pills, which reduce bleeding symptoms. 6
• Tranexamic acid serves as a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids. 6
• Second-line options include parenteral GnRH agonists (leuprolide acetate) and oral GnRH antagonists (elagolix, linzagolix, relugolix), which reduce both bleeding symptoms and tumor volume. 6
• Combination treatment with low doses of estrogen and progestin mitigates hypoestrogenic effects and is FDA-approved for fibroid-related heavy menstrual bleeding. 6

Essential Pre-Treatment Assessment

Mandatory Initial Evaluation

• Rule out pregnancy in all reproductive-age women with abnormal bleeding. 1, 7
• Assess for structural causes including fibroids, polyps, adenomyosis, endometrial pathology, or malignancy using combined transabdominal and transvaginal ultrasound with Doppler. 7
• Evaluate for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder. 1

Urgent Evaluation Criteria

• Bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation. 7, 2
• Assess for hemodynamic instability including tachycardia and hypotension. 7, 2

Treatment Algorithm by Clinical Scenario

No Cardiovascular Disease or Thrombotic Risk

1. Start NSAIDs (mefenamic acid, naproxen, or diclofenac) for 5-7 days during menstruation. 1
2. If inadequate response, advance to LNG-IUD. 1, 2
3. If LNG-IUD declined or contraindicated, use tranexamic acid 3.9-4 g/day for 4-5 days during menstruation. 3

Cardiovascular Disease or Thrombotic History Present

1. Avoid NSAIDs and tranexamic acid entirely. 1
2. Proceed directly to LNG-IUD as first-line therapy. 1, 2
3. If LNG-IUD contraindicated, consider combined oral contraceptives or cyclic progestins if no additional contraindications exist. 2, 5

Desire for Immediate Pregnancy

1. Use tranexamic acid as first-line since it does not affect fertility. 4
2. Avoid LNG-IUD and hormonal contraceptives. 4

Patients on Antiplatelet Therapy

• Reassess the indication for ongoing antiplatelet therapy and consider discontinuation if appropriate. 7, 2
• If antiplatelet therapy must continue, avoid NSAIDs and tranexamic acid. 7

Counseling for Treatment Adherence

• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities with certain treatments can improve treatment adherence. 1
• Inform patients that the LNG-IUD may cause irregular bleeding initially but typically results in light bleeding or amenorrhea over time. 1
• Explain that tranexamic acid is taken only during menstruation, not throughout the cycle. 3, 4