What is the best treatment approach for a patient experiencing heavy menstrual bleeding?

Treatment of Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95%. 1, 2, 3

Initial Assessment

Before initiating treatment, complete these essential evaluations:

• Rule out pregnancy in all reproductive-age women with abnormal bleeding 2, 3
• Assess hemodynamic stability: Check for tachycardia and hypotension; bleeding saturating a large pad/tampon hourly for ≥4 hours requires urgent evaluation 1
• Screen for structural causes: Evaluate for fibroids, polyps, adenomyosis, endometrial pathology, or malignancy using pelvic examination and/or transvaginal ultrasound 2, 4
• Consider coagulopathy testing if there is flooding (changing pad/tampon more than hourly), clots ≥1 inch diameter, prolonged menses, or personal/family bleeding history—up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 2, 5, 6
• Check complete blood count to assess for anemia and ferritin to evaluate iron deficiency 5

Treatment Algorithm

First-Line Treatment: LNG-IUD

For most women, start with the levonorgestrel-releasing intrauterine device (20 μg/day), which:

• Reduces menstrual blood loss by 71-95% 1, 2, 3
• Provides long-term contraception while treating bleeding 1, 3
• Often results in light bleeding or amenorrhea over time 2
• Can be used through menopause in perimenopausal women 2

Alternative First-Line: NSAIDs (with critical caveats)

There is contradictory guidance regarding NSAIDs as first-line therapy:

• The American College of Obstetricians and Gynecologists recommends NSAIDs as first-line pharmacologic treatment 2
• However, the American College of Cardiology recommends LNG-IUD as first-line, with NSAIDs as second-line only 1

If using NSAIDs:

• Prescribe mefenamic acid, naproxen, indomethacin, flufenamic acid, or diclofenac sodium for 5-7 days during menstruation only 2, 3
• Absolutely avoid in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 2
• Avoid in patients with history of spontaneous coronary artery dissection 1
• Never use aspirin—it does not reduce bleeding and may increase blood loss 2
• Screen for cardiovascular risk factors before initiating 2

Second-Line Hormonal Options

Cyclic oral progestins:

• Reduce bleeding by approximately 87% 1, 3
• May cause irregular bleeding patterns initially but often result in light menses 1

Combined hormonal contraceptives:

• Effective for reducing menstrual blood loss when hormonal options are appropriate 3
• For women with uterine fibroids, estrogen-progestin oral contraceptives are recommended first-line medical management 2

Second-Line Non-Hormonal Option: Tranexamic Acid

Tranexamic acid reduces menstrual blood loss by approximately 80 mL per cycle 2, 6

Absolute contraindications (must screen before prescribing):

• Active thromboembolic disease 2
• History of thrombosis 2
• Cardiovascular disease 2

Special Populations

Women with Uterine Fibroids

• First-line: NSAIDs and estrogen-progestin oral contraceptives 2
• Alternative: Tranexamic acid 2
• Second-line: GnRH agonists (parenteral) or GnRH antagonists (oral) to reduce bleeding and tumor volume 2
• FDA-approved option: Combination low-dose estrogen and progestin specifically for fibroid-related heavy menstrual bleeding 2

Women on Anticoagulation

• Reassess the indication for ongoing antiplatelet therapy, as it may worsen menstrual bleeding 1
• Consider hemostatic therapies like tranexamic acid (if no contraindications) or DDAVP for certain inherited bleeding disorders 6

Women with Inherited Bleeding Disorders

• DDAVP is used for heavy menstrual bleeding associated with certain inherited bleeding disorders 6
• Severe inherited bleeding disorders may require factor concentrate administration during menses 6

Surgical Options for Refractory Cases

When medical treatment fails:

1. Endometrial ablation: More effective long-term than oral medical treatments, can be performed as outpatient with low operative morbidity 1, 6
2. Hysterectomy: Definitive treatment when other options have failed; should only be considered after less invasive procedures have been attempted 1, 6, 4

Critical Counseling Points

• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities with certain treatments (especially LNG-IUD and progestins) can improve over time significantly improves treatment adherence 2, 3
• If bleeding persists despite treatment, consider alternative contraceptive methods or referral for surgical management 1