What is the management for prolonged menstrual periods?

Management of Prolonged Menstrual Periods

For prolonged menstrual bleeding, start with 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, 2

Immediate Assessment

Before initiating any treatment, complete the following essential evaluations:

• Pregnancy test is mandatory in all reproductive-age women before starting therapy 1
• Exclude sexually transmitted infections, particularly in reproductive-aged women 1, 2
• Assess for structural pathology including uterine fibroids, polyps, and adenomyosis through pelvic examination and transvaginal ultrasound 1, 3
• Check hemoglobin/hematocrit to evaluate for anemia, especially if bleeding saturates a large pad or tampon hourly for ≥4 hours 4, 3

Urgent evaluation is required if bleeding saturates a large pad or tampon hourly for at least 4 hours or if hemodynamic instability is present 4, 1

First-Line Medical Treatment

Combined oral contraceptives (COCs) are the recommended first-line therapy:

• Use monophasic formulations with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate 1, 2, 5
• COCs work by inducing regular shedding of a thinner endometrium, effectively reducing menstrual blood loss 1, 2
• Moderate-quality evidence shows COCs increase treatment success from 3% (placebo) to 12-77% in women with unacceptable heavy menstrual bleeding 6
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 1, 5

Important safety consideration: Screen for thrombotic risk factors before prescribing, as COCs increase venous thromboembolism risk three to fourfold 1, 2

Alternative Medical Options (When COCs Are Contraindicated or Ineffective)

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD 20 μg/d)

• Most effective progesterone-based option, achieving 71-95% reduction in menstrual blood loss 4, 1, 5
• Efficacy comparable to endometrial ablation 4, 3
• Superior to COCs for reducing menstrual blood loss (OR 0.21,95% CI 0.09 to 0.48) 6
• Backup contraception needed only if inserted >7 days after menses starts 5

Tranexamic Acid

• Reduces menstrual blood loss by 20-60% or approximately 80 mL/cycle 1, 2, 7, 3
• Appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 2, 3
• Critical contraindication: Avoid in women with active thromboembolic disease or history/risk of thrombosis 4, 1

Cyclic Oral Progestin

• Reduces bleeding by 87% and typically results in eventual reduction to light bleeding only 4, 1
• Can be used when combined hormonal methods are contraindicated 4

NSAIDs (Mefenamic Acid, Naproxen, Ibuprofen)

• Reduce menstrual blood loss by 20-60% 2, 7, 3
• Can be added for 5-7 days during bleeding episodes as adjunctive therapy 2, 5
• Avoid in women with cardiovascular disease due to association with MI and thrombosis 4, 1

Managing Breakthrough Bleeding on Treatment

If bleeding persists during the first 3-6 months of hormonal therapy:

• Reassure patients that unscheduled bleeding is common during the first 3-6 months and generally not harmful 4, 2, 5
• Re-evaluate for underlying problems if bleeding persists beyond initial months: check for IUD displacement, STDs, pregnancy, or new pathologic uterine conditions (polyps, fibroids) 4, 2
• Add NSAIDs for 5-7 days during bleeding episodes to reduce blood flow acutely 2, 5

For extended/continuous COC regimens with breakthrough bleeding:

• Consider a hormone-free interval of 3-4 consecutive days, but not during the first 21 days of use and not more than once per month 2, 5

Special Populations Requiring Careful Consideration

Women with cardiovascular disease or spontaneous coronary artery dissection:

• Hormonal therapy is relatively contraindicated and requires careful clinical judgment 4, 1, 5
• NSAIDs and tranexamic acid should generally be avoided due to association with MI and thrombosis 4, 1
• Consider second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency) as these avoid hormonal exposure 4, 3
• High-dose oral or injectable progestin-only medications may be considered short-term for hemodynamically unstable women 5

Women on antiplatelet therapy:

• Reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate 4
• Levonorgestrel-releasing IUD (20 μg/d) may be particularly useful as it provides local effect with minimal systemic absorption 4

Follow-Up Strategy

• No routine follow-up required for patients on COCs, but they should return for side effects or concerns 1, 2, 5
• Monitor blood pressure at follow-up visits for patients on COCs 5
• Assess satisfaction with the method and any health status changes at follow-up visits 2, 5
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1, 2

When to Consider Surgical Options

If medical management fails and bleeding persists:

• Counsel on alternative contraceptive methods and offer another method if desired 4, 2
• Second-generation endometrial ablation techniques have greater long-term efficacy than oral medical treatment for women not desiring future pregnancy 4, 3
• Hysterectomy should be performed by vaginal or laparoscopic routes if selected, but is not recommended as first-line treatment 3