What are the management options for a 47-year-old female with menorrhagia (heavy menstrual bleeding) and slightly irregular menstrual cycles?

Management of Heavy Menstrual Bleeding in a 47-Year-Old Female

For a 47-year-old woman with heavy menstrual bleeding and slightly irregular cycles, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment, reducing menstrual blood loss by 71-95% and often resulting in amenorrhea over time. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, you must rule out structural and pathologic causes:

• Perform a pregnancy test (β-hCG) – mandatory in all reproductive-age women with abnormal bleeding 1
• Check thyroid-stimulating hormone and prolactin levels to exclude endocrine causes 3, 1
• Obtain combined transabdominal and transvaginal ultrasound with Doppler as the first-line imaging study to identify polyps, adenomyosis, leiomyomas, or endometrial hyperplasia/malignancy 1
• Consider endometrial biopsy if she has risk factors for endometrial cancer (obesity, diabetes, hypertension, unopposed estrogen exposure) or if endometrial thickness ≥4 mm on ultrasound 1

At age 47 with irregular cycles, she is likely perimenopausal with ovulatory dysfunction, but you must exclude structural pathology before proceeding with medical management. 3

First-Line Medical Treatment Options

Levonorgestrel-Releasing IUD (LNG-IUD 20 μg/day)

This is the single most effective medical treatment for heavy menstrual bleeding:

• Reduces menstrual blood loss by 71-95%, with efficacy comparable to endometrial ablation 3, 2, 4
• Many women develop amenorrhea or oligomenorrhea by 2 years of use 3
• Effective even with structural causes like small-to-moderate fibroids and adenomyosis 4
• Provides highly effective contraception if still needed 5
• Counsel her that unscheduled spotting or light bleeding is expected during the first 3-6 months but decreases with continued use 3

Alternative First-Line Options if LNG-IUD is Declined

If she refuses the LNG-IUD or it is contraindicated:

Combined hormonal contraceptives (CHCs) are the second-line hormonal option:

• Can be given as oral contraceptive pills or transvaginal ring 4
• Less effective than LNG-IUD but still significantly reduce blood loss 4
• At age 47, assess cardiovascular risk factors before prescribing (smoking, hypertension, migraine with aura) 3

Tranexamic acid is the most effective non-hormonal option:

• Reduces menstrual blood loss by 34-60% 5, 4, 6
• Dose: 3.9-4 g per day for 4-5 days starting from the first day of menstruation 5
• Contraindicated if she has cardiovascular disease or active thromboembolic disease 5
• Does not provide contraception 5

NSAIDs (mefenamic acid, ibuprofen, naproxen):

• Reduce menstrual blood loss by 20-30% 2, 4, 6
• Dose: 5-7 days during menstruation 2
• Less effective than tranexamic acid or hormonal options but useful for women with marginally increased blood loss 4
• Avoid if she has cardiovascular disease due to MI and thrombosis risk 3, 2

Second-Line Medical Treatment

Oral progestogens (long-course):

• Medroxyprogesterone acetate 5-10 mg daily for 12-14 consecutive days per month 7
• Less effective than LNG-IUD or CHCs but can reduce bleeding by up to 87% 3
• Often results in irregular bleeding initially 3
• Short-course cyclic progestogens (≤14 days) are NOT effective for ovulatory women and should be avoided 4, 6

Surgical Options

If medical management fails after adequate trial (typically 3-6 months), is contraindicated, or she has significant structural pathology:

• Endometrial ablation – second-generation techniques provide long-term efficacy greater than oral medical treatment 3
• Hysterectomy – provides complete resolution and significantly better quality-of-life compared to other therapies 1
• Refer to gynecology for surgical evaluation 1

Critical Pitfalls to Avoid

• Do NOT use short-course cyclic progestogens (10-14 days per cycle) – they are ineffective for reducing menstrual blood loss in ovulatory women 4, 6
• Do NOT use aspirin – it does not reduce bleeding and may increase blood loss 3, 2
• Reassess cardiovascular risk before prescribing tranexamic acid or NSAIDs, as both are contraindicated in women with cardiovascular disease 3, 2, 5
• Do NOT delay endometrial assessment in a 47-year-old with irregular bleeding – she is at increased risk for endometrial hyperplasia and cancer 1

Treatment Algorithm

1. Rule out pregnancy, structural pathology, and endocrine causes with pregnancy test, TSH/prolactin, and pelvic ultrasound 3, 1
2. Offer LNG-IUD as first-line treatment unless contraindicated 1, 2, 4
3. If LNG-IUD declined: offer tranexamic acid (if no cardiovascular disease) or CHCs (if no cardiovascular risk factors) 5, 4
4. If medical management fails after 3-6 months: refer for surgical evaluation 1, 7