What are the treatment options for a patient with heavy menstrual bleeding?

Treatment of Heavy Menstrual Bleeding

NSAIDs are the recommended first-line pharmacologic treatment for heavy menstrual bleeding, prescribed for 5-7 days during menstruation only. 1, 2

First-Line Treatment: NSAIDs

Start with NSAIDs during active bleeding days only (5-7 days per cycle). Multiple NSAIDs have demonstrated statistically significant reductions in menstrual blood loss of 20-35%, including: 1, 3, 4

• Ibuprofen 400 mg every 4-6 hours (FDA-approved dosing for dysmenorrhea, also effective for heavy bleeding) 5
• Mefenamic acid 1
• Naproxen 1
• Diclofenac sodium 1

Critical contraindication: Avoid NSAIDs entirely in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis. 1 Screen for cardiovascular risk factors before initiating NSAID therapy. 1

Never use aspirin - it does not reduce bleeding and may actually increase blood loss. 1

Essential Initial Assessment Before Treatment

Before prescribing any treatment, you must: 1, 2

• Rule out pregnancy immediately with beta-hCG in all reproductive-age women 1, 2
• Assess for structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 1
• Evaluate for coagulopathies if clinically indicated - up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 1, 2
• Check for sexually transmitted diseases, medication interactions, and new pathologic uterine conditions 2

Second-Line Treatment Options

If NSAIDs fail after 1-3 cycles, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment, reducing menstrual blood loss by 71-95%. 1, 2, 6 Over time, many women experience only light menstrual bleeding or amenorrhea with the LNG-IUD. 1

Tranexamic acid is a non-hormonal alternative that reduces menstrual blood loss by approximately 80 mL per cycle (50% reduction). 1, 3, 4 However, tranexamic acid is absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease. 1

Combined oral contraceptives may reduce menstrual blood loss by approximately 50%, though evidence is limited. 4, 7

Treatment Algorithm

1. Start with NSAIDs (5-7 days during bleeding) for all patients without cardiovascular contraindications 1, 2
2. If bleeding persists after 1-3 cycles, consider LNG-IUD or tranexamic acid (if no thrombotic contraindications) 2, 6
3. If medical treatment fails and bleeding remains unacceptable, refer for surgical evaluation (endometrial ablation or hysterectomy) 2, 6

Important Counseling Points

Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities with certain treatments are generally not harmful can significantly improve treatment adherence. 8, 2 This is particularly important for hormonal treatments where irregular bleeding is common initially. 8

Common Pitfalls to Avoid

• Do not prescribe cyclical progestogens alone - they are ineffective for ovulatory menorrhagia unless taken at high doses (10-15 mg daily for 3 weeks out of 4). 4
• Do not exceed ibuprofen 3200 mg total daily dose 5
• Do not continue NSAIDs beyond 5-7 days per cycle to minimize gastrointestinal and cardiovascular risks 1, 5
• Do not assume bleeding will resolve without treatment - address the underlying issue 1