Medical Management for Cessation of Prolonged Menses
For prolonged menstrual bleeding, initiate NSAIDs (such as mefenamic acid 500 mg three times daily or ibuprofen 600-800 mg every 6-8 hours) for 5-7 days during bleeding as first-line therapy, and if this fails or is contraindicated, use short-term hormonal treatment with combined oral contraceptives or estrogen for 10-20 days. 1, 2
First-Line Treatment: NSAIDs
NSAIDs are the most appropriate initial medical intervention for prolonged menses, demonstrating significant reductions in menstrual blood loss across multiple studies. 2
Specific NSAID regimens include:
NSAIDs work by inhibiting prostaglandin synthesis, which reduces both bleeding volume and uterine hypercontractility. 3
Critical caveat: Avoid aspirin, as it has not demonstrated effectiveness and may actually increase blood loss in women with lower baseline menstrual blood loss. 1, 2
Contraindication alert: Women with cardiovascular disease should avoid NSAIDs due to increased risk of thrombosis and myocardial infarction. 2
Second-Line Treatment: Hormonal Therapy
If NSAIDs fail after one treatment cycle or are contraindicated, proceed to short-term hormonal treatment. 1
Hormonal treatment options include:
- Combined oral contraceptives (COCs) for 10-20 days during bleeding episodes 1
- Estrogen therapy for 10-20 days as an alternative to COCs 1
- These regimens are appropriate only if the patient is medically eligible (no contraindications to estrogen-containing products) 1
Rule Out Underlying Pathology First
Before attributing bleeding to hormonal imbalance, exclude:
- Pregnancy (perform pregnancy test) 4, 5
- Structural causes: fibroids, polyps, adenomyosis 4, 3
- Malignancy or endometrial hyperplasia 4, 5
- Sexually transmitted infections 1, 3
- Coagulation disorders 4
If any underlying gynecological problem is identified, treat the specific condition or refer for specialized care. 1
Long-Term Management Considerations
For women with recurrent prolonged menses who require ongoing management:
The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective long-term medical treatment, reducing menstrual blood loss by 71-95%. 4, 2
- The LNG-IUD (20 μg/day) has efficacy comparable to endometrial ablation for heavy menstrual bleeding 4
- Over time, many women experience only light menstrual bleeding or amenorrhea with the LNG-IUD 2
- This option is particularly effective for women on anticoagulation or antiplatelet therapy 4
Alternative long-term options include:
- Oral progestogens for 21 days per month 4
- Tranexamic acid during menstruation (5-7 days), though this should be avoided in women with cardiovascular disease or thrombotic risk 4, 2
Critical Pitfalls to Avoid
Do not underdose NSAIDs: Use full therapeutic doses (600-800 mg ibuprofen, not lower doses) for maximum effectiveness. 3
Do not delay treatment while awaiting diagnostic workup: Start empiric NSAID therapy immediately while investigating underlying causes. 3
Do not continue ineffective treatment beyond 1-2 cycles: If bleeding persists despite appropriate NSAID therapy, this indicates need for hormonal treatment or further investigation. 1, 3
Do not use hormonal contraceptives to mask symptoms without first ruling out pregnancy and pathology, particularly in cases of persistent or recurrent abnormal bleeding. 5
Cessation of menses alone is not an adequate indicator of successful treatment if the patient required ovarian suppression, as incomplete suppression may occur. 1
When to Escalate Care
If bleeding persists despite both NSAID and short-term hormonal treatment, or if the woman finds the bleeding unacceptable despite treatment:
- Perform transvaginal ultrasound to evaluate for structural abnormalities 3
- Consider hysteroscopy for direct visualization 4
- Counsel on alternative long-term management options including LNG-IUD, endometrial ablation, or surgical intervention 4
- Refer to gynecology if medical management fails after appropriate trials 1