What is the initial management for a 39-year-old woman with menorrhagia (heavy menstrual bleeding)?

Initial Management of Heavy Menstrual Bleeding in a 39-Year-Old Woman

Begin with combined oral contraceptives containing 30-35 μg ethinyl estradiol (with levonorgestrel or norgestimate) as first-line treatment after excluding pregnancy, infection, and structural lesions. 1

Immediate Evaluation Required

Before initiating any treatment, you must rule out:

• Pregnancy - Perform β-hCG testing in all reproductive-age women with abnormal bleeding 1, 2
• Sexually transmitted infections - Screen for STDs, particularly in reproductive-aged women 1
• Structural pathology - Consider transvaginal ultrasound to identify polyps, fibroids, adenomyosis, or endometrial abnormalities 2
• Thyroid dysfunction - Check TSH levels to rule out ovulatory dysfunction 2

First-Line Medical Treatment

Monophasic combined oral contraceptives (COCs) are the initial therapy of choice 1:

• Use formulations with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate 1
• These reduce menstrual blood loss by inducing regular shedding of a thinner endometrium 1
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 1
• Before prescribing, assess thrombotic risk factors as COCs increase venous thromboembolism risk three to fourfold 1

If Bleeding Persists on COCs

When bleeding continues despite COC therapy, add:

• NSAIDs for 5-7 days during bleeding episodes (mefenamic acid, indomethacin, or diclofenac) - reduces blood loss by 20-60% 1, 3
• Alternatively, hormonal treatment for 10-20 days if medically eligible 1
• Consider a hormone-free interval of 3-4 consecutive days for heavy bleeding in extended/continuous regimens, but avoid this during the first 21 days or more than once per month 1

Alternative First-Line Options

If COCs are contraindicated or undesired:

• Tranexamic acid - reduces menstrual blood loss by 40-60%, most effective non-hormonal option 2, 3
  • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2
• NSAIDs alone (mefenamic acid preferred) - reduces blood loss by 20-60% 1, 4
  • Avoid aspirin as it can paradoxically increase bleeding 2

Most Effective Long-Term Treatment

The levonorgestrel-releasing intrauterine system (LNG-IUS, 20 μg/day) is the most effective medical treatment 1, 5:

• Reduces menstrual blood loss by 71-95% 2, 5
• Efficacy comparable to endometrial ablation or hysterectomy 2, 4
• Particularly useful if patient desires long-term contraception or has contraindications to estrogen 5
• Works even with some structural causes like fibroids and adenomyosis 5

Patient Counseling

Reassure the patient that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and is generally not harmful 1:

• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1
• This applies to all hormonal treatments including COCs and LNG-IUS 6, 1

When to Escalate Care

If bleeding persists after 3 months of medical treatment and the patient finds it unacceptable, counsel on alternative methods 1:

• Consider switching from COCs to LNG-IUS if not already tried 5
• Refer to gynecology if medical management fails after adequate trial 2
• Urgent referral needed if: hemodynamic instability, endometrial thickness ≥4 mm (if imaging performed), or suspicion of malignancy 2

Special Considerations

• Check for bleeding disorders (von Willebrand disease) if there is personal/family history of easy bruising, epistaxis, or dental bleeding, or if bleeding is refractory to initial treatment 2
• Monitor blood pressure at follow-up visits for patients on COCs 1
• No routine follow-up visit required, but patients should return for side effects or concerns 1