What other nonsteroidal anti-inflammatory drugs (NSAIDs) can be given to a 14-year-old female patient with menometrorrhagia, severe anemia, and symptoms of pallor, headache, and dizziness?

NSAIDs for Heavy Menstrual Bleeding in a 14-Year-Old

For this 14-year-old with menometrorrhagia and severe anemia, NSAIDs are the recommended first-line pharmacologic treatment, specifically mefenamic acid, naproxen, or ibuprofen, taken for 5-7 days during menstruation only. 1

Specific NSAID Options

First-Line Choices

• Mefenamic acid is highly effective, reducing menstrual blood loss by 20-60% and demonstrating sustained reductions over long-term use 2, 3, 4
• Naproxen has demonstrated statistically significant reductions in menstrual blood loss 1
• Ibuprofen is effective and widely available, with proven efficacy in reducing menstrual bleeding 1, 5
• Diclofenac sodium is another validated option for menstrual blood loss reduction 1

Dosing and Duration

• Administer NSAIDs only during the 5-7 days of active menstrual bleeding, not continuously 1
• Treatment should be limited to menstruation days to minimize adverse effects while maintaining efficacy 1

Critical Contraindications for This Patient

Absolute Contraindications

• Avoid NSAIDs entirely if cardiovascular disease is present due to increased risk of myocardial infarction and thrombosis 6, 1
• Do not use aspirin - it does not reduce bleeding and may actually increase blood loss 1
• NSAIDs are contraindicated in patients with active peptic ulcer disease, bleeding disorders, or severe renal impairment 5

Special Considerations for Adolescents

• Screen for underlying bleeding disorders, as up to 20% of women with heavy menstrual bleeding may have an inherited coagulopathy 1
• Assess for signs of von Willebrand disease or platelet dysfunction before initiating therapy 7
• Monitor for gastrointestinal side effects, though these are generally well-tolerated in short-term menstrual use 8

Alternative Non-Hormonal Option

If NSAIDs are contraindicated or ineffective, tranexamic acid is the alternative non-hormonal treatment, reducing menstrual blood loss by approximately 80 mL per cycle 1. However, tranexamic acid has critical contraindications:

• Absolutely contraindicated in active thromboembolic disease, history of thrombosis, or cardiovascular disease 9, 1
• Requires dose adjustment in renal impairment due to risk of neurotoxicity 9
• Should be avoided in this patient population given the theoretical thrombotic concerns 9

Concurrent Management Requirements

Address the Severe Anemia

• Iron supplementation is mandatory to correct anemia and replenish body stores 5
• Ferrous sulfate 200 mg three times daily is the standard treatment 5
• Continue iron for three months after correction of anemia to replenish stores 5
• Ascorbic acid enhances iron absorption and should be considered if response is poor 5

Monitoring Parameters

• Hemoglobin should rise by 2 g/dL after 3-4 weeks of iron therapy 5
• Failure to respond suggests continued blood loss, poor compliance, misdiagnosis, or malabsorption 5
• Monitor hemoglobin and MCV at three-month intervals for one year, then annually 5

Clinical Pitfalls to Avoid

• Never combine multiple NSAIDs - concomitant use increases gastrointestinal toxicity without improving efficacy 10
• Do not use NSAIDs continuously - limit to menstrual days only to prevent rebound headaches and adverse effects 5
• Screen for cardiovascular risk factors before initiating any NSAID therapy 1
• Avoid NSAIDs if anticoagulants are being used - risk of GI bleeding increases three to six times 5
• Rule out pregnancy with beta-hCG testing before starting any treatment 6, 1

When to Escalate Treatment

If NSAIDs fail after appropriate trial:

• Consider levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95% and is the most effective medical treatment 1
• Refer to gynecology if medical management fails, endometrial sampling shows hyperplasia/malignancy, or structural abnormalities are identified 6