What is the best treatment approach for a female patient of reproductive age experiencing prolonged heavy menstrual bleeding?

Treatment of Prolonged Heavy Menstrual Bleeding in Reproductive-Age Women

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment for prolonged heavy menstrual bleeding, reducing menstrual blood loss by 71-95% and should be considered first-line therapy for women of reproductive age. 1, 2, 3

Immediate Assessment Required

Before initiating treatment, you must systematically rule out serious underlying conditions:

• Perform a pregnancy test (β-hCG) immediately in all reproductive-age women—this is mandatory and non-negotiable 2, 4, 3
• Assess hemodynamic stability urgently if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
• Order transvaginal ultrasound to identify structural causes including fibroids, polyps, adenomyosis, endometrial hyperplasia, or malignancy 2, 3
• Check TSH and prolactin levels to rule out ovulatory dysfunction 2
• Screen for bleeding disorders (von Willebrand disease, platelet dysfunction) if there is personal or family history of easy bruising, epistaxis, or dental bleeding—up to 20% of women with heavy menstrual bleeding have an underlying coagulopathy 2, 3, 5, 6

First-Line Long-Term Treatment

Start with the LNG-IUD as definitive therapy unless contraindicated:

• Reduces menstrual blood loss by 71-95%, with efficacy comparable to endometrial ablation or hysterectomy 1, 2, 3
• Many women eventually experience only light bleeding or amenorrhea 3
• Provides superior contraceptive protection simultaneously 4
• Can be used through menopause in perimenopausal women 3
• Evidence demonstrates no increase in adverse effects when used for heavy bleeding 1

Acute Bleeding Management (While Awaiting LNG-IUD Placement)

If immediate bleeding control is needed before LNG-IUD insertion:

Option 1: Tranexamic Acid (Most Effective)

• Reduces menstrual blood loss by 40-60% 2
• Absolute contraindications: Active thromboembolic disease, history of thrombosis, cardiovascular disease, or myocardial infarction 2, 3

Option 2: NSAIDs (If Tranexamic Acid Contraindicated)

• Use mefenamic acid or naproxen for 5-7 days during active bleeding 1, 2, 3
• Reduces blood loss by 20-60% 2, 3
• Critical contraindication: Avoid in women with cardiovascular disease, history of myocardial infarction, or thrombosis risk due to increased MI risk 1, 3
• Never use aspirin—it paradoxically increases bleeding 2, 3

Option 3: Combined Oral Contraceptives or Estrogen

• Use for 10-20 days if medically eligible 1, 4
• Provides endometrial stabilization but carries higher thrombotic risk than progestin-only methods 4, 3

Alternative Hormonal Options

If the LNG-IUD is declined or contraindicated:

• Cyclic oral progestins (norethindrone acetate 5 mg daily) reduce bleeding by 87% 1, 4
• Combined hormonal contraceptives can regulate cycles but have higher thrombotic risk 4, 3
• Note: Cyclic progestogens do NOT significantly reduce bleeding in ovulatory women 7

When to Refer to Gynecology (Urgent)

Immediate referral is warranted if:

• Medical treatment fails after 3 months 2
• Endometrial biopsy shows hyperplasia or malignancy 2
• Persistent hemodynamic instability despite treatment 2
• Structural pathology (fibroids, polyps) identified on imaging requiring surgical intervention 4, 3

When to Refer to Hematology

Refer for coagulopathy evaluation if:

• Personal or family history of bleeding disorders (epistaxis, easy bruising, dental bleeding) 2, 3
• Bleeding refractory to initial treatment 2
• Patient on anticoagulation therapy requiring management adjustment 2

Critical Pitfalls to Avoid

Do not assume bleeding will resolve spontaneously—prolonged heavy bleeding causes iron-deficiency anemia, significantly impairs quality of life, and may indicate serious underlying pathology 2, 3, 5

Do not use NSAIDs or tranexamic acid in women with cardiovascular disease—both are associated with increased risk of myocardial infarction and thrombosis 1, 2, 3

Do not delay evaluation for structural causes—unusually heavy bleeding should raise suspicion of malignancy, particularly in women over 40 or those with risk factors for endometrial cancer 1, 2

Do not prescribe cyclic progestins alone for ovulatory bleeding—they are ineffective in this population 7

Enhanced Counseling Improves Outcomes

• Explain expected bleeding patterns with each treatment option 4, 3
• Reassure patients that irregular bleeding with hormonal treatments does not indicate contraceptive failure 4
• Emphasize that the LNG-IUD may cause irregular bleeding initially but typically results in dramatically reduced or absent menses over time 3
• Enhanced counseling significantly improves treatment adherence and reduces discontinuation rates 4, 3