What are the treatment options for a 42-year-old female patient experiencing heavy menstrual bleeding?

Treatment of Heavy Menstrual Bleeding in a 42-Year-Old Woman

Start with NSAIDs (naproxen, mefenamic acid, or ibuprofen) for 5-7 days during menstruation as first-line therapy, then escalate to a levonorgestrel-releasing intrauterine device (LNG-IUD) if bleeding persists after 1-3 cycles. 1, 2, 3

Initial Assessment Required

Before initiating treatment, you must:

• Rule out pregnancy in all reproductive-age women with abnormal bleeding 1, 3
• Assess for structural causes including fibroids, polyps, adenomyosis, or endometrial pathology through pelvic examination and/or transvaginal ultrasonography 1, 4
• Screen for coagulopathies if the patient reports flooding (changing pad/tampon more than hourly), clots ≥1 inch diameter, or has personal/family history of bleeding disorders, as up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 1, 5
• Check hemoglobin/ferritin to assess for anemia 5, 4
• Evaluate thyroid function as thyroid dysfunction is a common reversible cause 4, 6

First-Line Treatment: NSAIDs

NSAIDs are the recommended first-line pharmacologic treatment, prescribed for 5-7 days during menstruation only. 1, 3

Effective options include:

• Mefenamic acid 7, 1
• Naproxen 1, 2
• Ibuprofen 1
• Diclofenac sodium 7, 1

Critical contraindication: Avoid NSAIDs entirely in women with cardiovascular disease, as they increase risk of myocardial infarction and thrombosis. 1 Screen for cardiovascular risk factors before prescribing. 1

Do not use aspirin as it does not reduce bleeding and may actually increase blood loss. 1

Second-Line Treatment: LNG-IUD

If bleeding persists after 1-3 cycles of NSAIDs, the LNG-IUD is the most effective medical treatment available. 1, 2, 3

The LNG-IUD provides:

• 71-95% reduction in menstrual blood loss, the highest efficacy of any medical treatment 1, 2, 8
• Many women eventually experience only light bleeding or amenorrhea 1
• Dual benefit of contraception 2, 8
• Can be used through menopause in perimenopausal women 1

Counseling point: Inform patients that unscheduled spotting or light bleeding is common during the first 3-6 months of use, is generally not harmful, and decreases with continued use. Enhanced counseling about expected bleeding patterns improves treatment adherence. 7, 2, 3

Alternative Second-Line Options

Tranexamic Acid (Non-Hormonal)

• Reduces menstrual blood loss by approximately 80 mL per cycle 1
• Useful for women who cannot or prefer not to use hormonal methods 1, 4
• Absolute contraindications: Active thromboembolic disease, history of thrombosis, or cardiovascular disease 1, 9
• Avoid concomitant use with pro-thrombotic medications including hormonal contraceptives 9

Combined Hormonal Contraceptives

• Effective for reducing menstrual blood loss when hormonal options are appropriate 2, 8
• Second choice after LNG-IUD for women desiring contraception 8

Cyclic Oral Progestins

• Reduce bleeding by approximately 87% 2
• May result in irregular bleeding patterns 2
• Useful for women with anovulatory bleeding 4, 6

Treatment Algorithm

1. Initiate NSAIDs for 5-7 days during menstruation 1, 3
2. Reassess after 1-3 cycles: If bleeding persists and is unacceptable to the patient, proceed to step 3 3
3. Offer LNG-IUD as most effective option, or tranexamic acid if hormonal methods contraindicated 1, 2, 3
4. If medical management fails after adequate trial, counsel on alternative methods or refer for surgical evaluation (endometrial ablation, hysterectomy) 7, 4

Critical Pitfalls to Avoid

• Do not overlook underlying bleeding disorders: Women with flooding, large clots, or bleeding history require hematology referral before assuming structural or hormonal causes 5
• Do not prescribe NSAIDs without cardiovascular screening: This population (42 years old) may have unrecognized cardiovascular risk factors 1
• Do not combine tranexamic acid with hormonal contraceptives due to increased thrombotic risk 9
• Do not assume anovulation without evaluation: At age 42, structural causes (fibroids, polyps, adenomyosis) become increasingly common and require imaging 4, 6

Special Consideration for Age 42

At this age, consider:

• Perimenopausal transition may be contributing to irregular bleeding patterns 4
• LNG-IUD can be left in place through menopause, making it particularly advantageous for this age group 1
• Increased likelihood of structural pathology (fibroids, polyps) warrants lower threshold for imaging 4, 6
• Endometrial sampling should be performed if risk factors for endometrial cancer exist (obesity, diabetes, chronic anovulation) or if bleeding is unresponsive to initial medical therapy 4