Treatment of Heavy Vaginal Bleeding
The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line medical treatment for heavy menstrual bleeding, with efficacy comparable to surgical interventions while preserving the uterus. 1
Initial Management Priorities
Before initiating treatment, you must exclude pregnancy (β-hCG test), structural lesions (pelvic ultrasound), infection (cervical cultures if indicated), and bleeding disorders through appropriate laboratory testing. 2 In women over 45 years old, endometrial biopsy is essential to exclude endometrial hyperplasia or malignancy. 2
Simultaneously initiate oral iron supplementation with ferrous sulfate 200 mg three times daily to correct anemia and replenish iron stores—do not delay iron therapy while waiting for bleeding control. 1 Iron supplementation should continue for three months after hemoglobin normalizes to replenish body stores, with expected hemoglobin rise of 2 g/dL after 3-4 weeks. 1 Adding ascorbic acid (vitamin C) enhances iron absorption when response is poor. 1
First-Line Treatment Algorithm
Primary Option: LNG-IUS
The LNG-IUS provides dual benefits of bleeding control and contraception, with effectiveness comparable to endometrial ablation or hysterectomy. 1 This should be your default first-line choice for most patients with heavy menstrual bleeding. 1, 2
Alternative First-Line Options (when LNG-IUS is contraindicated or declined):
Tranexamic acid is the second most effective first-line treatment, reducing menstrual blood loss by 20-60% and serving as the preferred non-hormonal alternative. 1, 3, 4 The recommended dosage is 3.9-4 g/day for 4-5 days starting from the first day of menstruation. 3 Tranexamic acid is significantly more effective than placebo, NSAIDs, oral luteal phase progestins, and etamsylate. 4, 5
Combined hormonal contraceptives (CHCs) with 30-35 μg ethinyl estradiol are effective for regulating menstrual cycles and reducing bleeding, particularly appropriate for younger women who also desire contraception. 1, 2
NSAIDs provide modest reduction in menstrual blood loss and can be used as adjunctive therapy, but are less effective than tranexamic acid. 1, 4
Management of Treatment Failures
If Heavy Bleeding Persists Despite Combined Oral Contraceptive Pills:
Add tranexamic acid to the COCP as first-line escalation therapy. 6 If this combination fails, discontinue COCP and insert an LNG-IUS. 6, 7 Depot medroxyprogesterone acetate (DMPA) is an alternative for patients who cannot tolerate or have contraindications to LNG-IUS. 7
For third-line therapy when bleeding persists, consider combined DDAVP/COCP/TXA, though evidence for this approach is limited. 6
Special Populations
Bleeding Disorder of Unknown Cause (BDUC):
For women with documented bleeding disorders but normal hemostatic testing, tranexamic acid is favored for prophylaxis (71% for minor surgery, 59% for major surgery, 58% for pregnancy). 6 In the event of breakthrough bleeding, first-line treatment includes TXA alone or combined with DDAVP. 6
Perioperative Management:
Tranexamic acid significantly reduces perioperative blood loss in gynecologic surgery, including myomectomy and hysterectomy, and should be considered during major gynecologic procedures. 8, 5
Monitoring and Follow-Up
Reassess patients at 3-6 months to evaluate treatment response, menstrual pattern normalization, and hemoglobin levels. 1 Check hemoglobin concentration at three-monthly intervals for one year, then annually. 1 If bleeding persists and the patient finds it unacceptable, counsel on alternative contraceptive methods and offer another option. 6
Critical Safety Considerations
Active thromboembolic disease is an absolute contraindication to tranexamic acid. 3 In the United States, a history of thrombosis or thromboembolism, or an intrinsic risk for thrombosis or thromboembolism are also considered contraindications. 6, 3 However, long-term studies demonstrate that the incidence of thrombosis in women treated with tranexamic acid is comparable to the spontaneous frequency in untreated women. 4, 5
Never use aspirin for bleeding control—it may increase menstrual blood loss. 1 Tranexamic acid has few adverse effects, which are mainly mild, and is not associated with increased side effects compared to placebo, NSAIDs, or oral progestogens. 4, 5
Surgical Options
If medical management fails or structural lesions require intervention, consider endometrial ablation or hysterectomy. 2 However, medical therapy should be exhausted first, as LNG-IUS provides efficacy comparable to surgical interventions while preserving the uterus. 1