What is the best management approach for a woman with heavy menstrual bleeding, low Luteinizing Hormone (LH) levels, low Follicle-Stimulating Hormone (FSH) levels, and elevated estradiol levels?

Management of Heavy Menstrual Bleeding with Low LH/FSH and Elevated Estradiol

This hormonal pattern (low LH 0.5, low FSH 1.3, elevated estradiol 102) suggests anovulatory bleeding with unopposed estrogen, and the first-line treatment is a levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95% and is the most effective medical therapy available. 1

Immediate Assessment Required

Rule out pregnancy first - all reproductive-age women with abnormal bleeding require a β-hCG test before any treatment, as this is an absolute priority regardless of hormonal patterns 2, 1.

Assess bleeding severity urgently if she is saturating a large pad or tampon hourly for at least 4 hours, as this requires immediate evaluation for hemodynamic instability 2, 3.

Evaluate for structural causes with combined transabdominal and transvaginal ultrasound with Doppler to exclude polyps, fibroids, adenomyosis, or endometrial pathology that could be contributing to the bleeding 2.

Understanding This Hormonal Pattern

Your patient's labs show anovulatory bleeding with unopposed estrogen exposure:

• Low LH and FSH with elevated estradiol indicates the pituitary is suppressed by the elevated estrogen, but ovulation is not occurring 4
• This creates continuous estrogen stimulation without progesterone opposition, leading to endometrial proliferation and irregular, heavy bleeding 4
• This pattern is common in perimenopausal women, PCOS, or other ovulatory dysfunction 2, 5

First-Line Treatment: LNG-IUD

The levonorgestrel-releasing intrauterine device is superior to all other medical treatments for heavy menstrual bleeding and directly addresses the unopposed estrogen problem 1, 3:

• Reduces menstrual blood loss by 71-95%, far exceeding other options 1, 3
• Provides local progestin effect to counteract the unopposed estrogen on the endometrium 1
• Over time, most women experience only light bleeding or amenorrhea 1
• Can be used through menopause in perimenopausal women 1

Alternative First-Line Options

If LNG-IUD is declined or contraindicated, use cyclic oral progestins:

• Reduces bleeding by approximately 87% and provides the progesterone opposition needed to stabilize the endometrium 3
• Addresses the core pathophysiology of unopposed estrogen 3
• May result in irregular bleeding initially but often reduces menses to light bleeding 3

NSAIDs for 5-7 days during menstruation only can be added to hormonal therapy 1:

• Multiple NSAIDs (mefenamic acid, naproxen, indomethacin) significantly reduce menstrual blood loss 1
• Critical contraindication: Absolutely avoid in women with cardiovascular disease due to increased MI and thrombosis risk 1, 3
• Never use aspirin - it does not reduce bleeding and may increase blood loss 1

Second-Line Options

Tranexamic acid is a non-hormonal alternative that reduces menstrual blood loss by approximately 80 mL per cycle 1:

• Absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 1
• Does not address the underlying hormonal imbalance but treats the bleeding symptomatically 1

Combined hormonal contraceptives can be considered but are less effective than LNG-IUD 1:

• Provide both estrogen and progestin to regulate the cycle 1
• May have higher thrombotic risk than other options 1

Critical Pitfalls to Avoid

Do not assume this will resolve spontaneously - unopposed estrogen exposure increases risk of endometrial hyperplasia and malignancy over time 2, 1.

Screen for endometrial pathology if she has risk factors: obesity, diabetes, hypertension, or age >40 years, as unopposed estrogen is a major risk factor for endometrial cancer 2.

Reassess antiplatelet therapy if she is on any antiplatelet agents, as 70% of women on anticoagulation experience heavy menstrual bleeding 2.

When to Refer to Gynecology

Refer immediately if 2:

• Endometrial thickness ≥4 mm on ultrasound in postmenopausal women
• Any endometrial sampling shows hyperplasia or malignancy
• Medical management fails after adequate trial
• Structural abnormalities requiring surgical intervention

Surgical options after failed medical management include endometrial ablation or hysterectomy, with hysterectomy providing complete resolution and significantly better quality of life 2, 3.