What is the approach to managing a patient with prolonged menstruation?

Approach to Prolonged Menstruation

NSAIDs are the first-line treatment for prolonged menstrual bleeding, prescribed for 5-7 days during menstruation only, with tranexamic acid as a highly effective alternative if NSAIDs fail or are contraindicated. 1

Initial Assessment

Before initiating treatment, systematically evaluate for underlying causes:

• Rule out pregnancy in all reproductive-age women presenting with abnormal bleeding 1
• Assess for structural pathology including fibroids, polyps, adenomyosis, endometrial pathology, or malignancy through pelvic examination and vaginal sonography 1, 2
• Screen for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1
• Evaluate for IUD displacement, STDs, or medication interactions in women using contraceptive devices or hormonal methods 3

First-Line Medical Treatment

NSAIDs should be prescribed for 5-7 days during active bleeding only:

• Multiple NSAIDs demonstrate statistically significant reductions in menstrual blood loss, including mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium 1
• Mefenamic acid reduces blood loss by approximately 20% 4
• Avoid aspirin, as it does not reduce bleeding and may actually increase blood loss in women with lower baseline menstrual blood loss 1

Critical NSAID Contraindications

Screen for cardiovascular disease before prescribing NSAIDs:

• NSAIDs must be avoided in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 1
• This screening step is essential and non-negotiable before initiating therapy 1

Second-Line Medical Treatment

If NSAIDs fail or are contraindicated, proceed to:

Tranexamic Acid (Preferred Non-Hormonal Option)

• Reduces menstrual blood loss by 34-59% over 2-3 cycles and by approximately 80 mL per cycle 1, 5, 4
• More effective than NSAIDs, with one study showing 54% reduction in blood loss compared to 20% with mefenamic acid 4
• Dosing: 1-1.5 g three times daily for 5 days during menstruation 5, 4
• Improves hemoglobin and ferritin levels in women with heavy menstrual bleeding 6

Absolute contraindications for tranexamic acid:

• Active thromboembolic disease 1
• History of thrombosis or thromboembolism 3, 1
• Cardiovascular disease 1

Levonorgestrel-Releasing Intrauterine Device (Most Effective Overall)

• The LNG-IUD is the most effective medical treatment, reducing menstrual blood loss by 71-95% 1
• Over time, many women experience only light menstrual bleeding or amenorrhea 3, 1
• Can be used through menopause in perimenopausal women 1
• More effective than tranexamic acid (96% reduction after 12 months vs. 34-59%) 5

Context-Specific Management

For Women Using Copper IUDs

If prolonged bleeding occurs with Cu-IUD use:

• Counsel that heavy or prolonged bleeding is common during the first 3-6 months and generally not harmful 3
• If bleeding persists beyond 3-6 months, evaluate for Cu-IUD displacement, STDs, pregnancy, or new pathologic uterine conditions 3
• Treat with NSAIDs for 5-7 days during bleeding if no underlying pathology is found 3
• If bleeding remains unacceptable despite treatment, counsel on alternative contraceptive methods 3

For Women with Uterine Fibroids

• First-line medical management includes NSAIDs and estrogen-progestin oral contraceptive pills 1
• Tranexamic acid is a nonhormonal alternative for fibroid-related bleeding 1
• Second-line options include parenteral GnRH agonists and oral GnRH antagonists, which reduce both bleeding and tumor volume 1

Treatment Algorithm

1. Rule out pregnancy, structural pathology, and coagulopathies
2. Screen for cardiovascular disease before prescribing NSAIDs or tranexamic acid
3. Start NSAIDs (5-7 days during menstruation) if no contraindications exist 1
4. If NSAIDs fail or are contraindicated, use tranexamic acid (1-1.5 g three times daily for 5 days) 5, 4
5. If medical therapy fails, consider LNG-IUD as the most effective long-term option 1
6. Provide enhanced counseling about expected bleeding patterns, as this improves treatment adherence 3, 1

Common Pitfalls

• Do not use aspirin for menstrual bleeding reduction, as it may worsen bleeding 1
• Do not prescribe tranexamic acid without screening for thrombotic risk factors, as it is absolutely contraindicated in women with thromboembolic disease 3, 1
• Do not dismiss bleeding as "normal" in Cu-IUD users beyond 3-6 months without evaluating for underlying pathology 3
• Do not continue ineffective treatment indefinitely—if bleeding persists and is unacceptable to the patient, offer alternative methods 3