What is the best course of treatment for a patient with persistent heavy menstrual bleeding for 2 months?

Management of Persistent Heavy Menstrual Bleeding for 2 Months

For a patient with persistent heavy menstrual bleeding for 2 months, initiate combined oral contraceptives containing 30-35 μg ethinyl estradiol as first-line treatment after ruling out pregnancy, infection, and structural pathology. 1

Initial Evaluation

Before initiating any treatment, perform the following essential assessments:

• Rule out pregnancy with β-hCG testing in all reproductive-age women 1, 2
• Screen for sexually transmitted infections, particularly in reproductive-aged women 1, 2
• Perform transvaginal ultrasound to identify polyps, fibroids, adenomyosis, or endometrial abnormalities 1
• Check TSH levels to rule out thyroid dysfunction causing ovulatory dysfunction 1
• Assess for bleeding disorders (von Willebrand disease) if there is personal/family history of easy bruising, epistaxis, dental bleeding, or if bleeding is refractory to initial treatment 1

First-Line Medical Treatment

Monophasic combined oral contraceptives are the initial therapy of choice, reducing menstrual blood loss by inducing regular shedding of a thinner endometrium 1. These also improve acne and reduce the risk of endometrial and ovarian cancers 1.

Critical caveat: Before prescribing COCs, assess thrombotic risk factors as they increase venous thromboembolism risk three to fourfold 1.

If Bleeding Persists on COCs

If bleeding continues despite COC therapy, add:

• NSAIDs for 5-7 days during bleeding episodes, which reduces blood loss by 20-60% 1, 3
• Specific effective options include mefenamic acid 500 mg three times daily or celecoxib 200 mg daily 2
• Alternatively, hormonal treatment for 10-20 days can be considered if medically eligible 1, 3

Important pitfall: Avoid aspirin as it can paradoxically increase bleeding 3

Alternative Non-Hormonal Options

If hormonal contraception is contraindicated or undesired:

• Tranexamic acid reduces menstrual blood loss by 40-60% and is the most effective non-hormonal option 1, 3
• Contraindication: Active thromboembolic disease or history/risk of thrombosis 1, 3
• NSAIDs alone (such as mefenamic acid) can reduce blood loss by 20-60% 1

Most Effective Long-Term Treatment

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment, reducing menstrual blood loss by 71-95% 1, 3. Its efficacy is comparable to endometrial ablation or hysterectomy 1.

Patient Counseling

Reassure the patient that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and is generally not harmful 1. Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1, 2.

When to Re-Evaluate

If bleeding persists despite initial treatment:

• Re-evaluate for underlying gynecological problems including displacement of IUD (if applicable), infection, pregnancy, or new uterine pathology 3, 2
• Consider endometrial biopsy in women ≥35 years with recurrent anovulation, women <35 years with risk factors for endometrial cancer, or women with excessive bleeding unresponsive to medical therapy 4
• Counsel on alternative contraceptive methods and offer another method if desired 3, 2

Treatment Algorithm Summary

1. Exclude pregnancy, infection, structural pathology (ultrasound), and thyroid dysfunction 1
2. Start COCs 30-35 μg ethinyl estradiol (if no contraindications) 1
3. If bleeding persists: Add NSAIDs 5-7 days during bleeding 1, 3
4. If still inadequate: Consider LNG-IUS for most effective long-term control 1, 3
5. Alternative: Tranexamic acid if hormones contraindicated (check thrombosis risk) 1, 3

Monitor blood pressure at follow-up visits for patients on COCs 1.