What are the treatment options for a female patient of reproductive age experiencing menorrhagia (heavy menstrual bleeding)?

How to Slow Down and Regulate Heavy Periods

Start with NSAIDs (like ibuprofen or naproxen) taken for 5-7 days during menstruation as first-line treatment, or consider the levonorgestrel IUD (LNG-IUD) which reduces menstrual blood loss by 71-95% and is the most effective medical option available. 1

Immediate First-Line Treatment Options

NSAIDs (Most Accessible First-Line)

• Take NSAIDs for 5-7 days during active bleeding only – this includes mefenamic acid, naproxen, indomethacin, or diclofenac 2, 1
• These medications reduce menstrual blood loss by 20-60% 3
• Critical warning: Avoid NSAIDs completely if you have cardiovascular disease, as they increase risk of heart attack and blood clots 4, 1
• Do NOT use aspirin – it does not reduce bleeding and may actually increase blood loss 1

Levonorgestrel IUD (Most Effective Option)

• The LNG-IUD is the single most effective medical treatment, reducing bleeding by 71-95% 1, 5
• Effectiveness is comparable to surgical endometrial ablation 6
• Over time, many women experience only light bleeding or complete absence of periods 1
• Can be used through menopause in perimenopausal women 1

Second-Line Medical Options

Tranexamic Acid

• Reduces menstrual blood loss by approximately 80 mL per cycle 1
• Non-hormonal alternative for women who cannot use hormones 1
• Absolutely contraindicated if you have history of blood clots, active clotting disorders, or cardiovascular disease 1

Combined Hormonal Contraceptives (Birth Control Pills)

• Effective second-line option after LNG-IUD 5
• Contain both estrogen and progestin 6
• Induce regular shedding of a thinner uterine lining 7

Oral Progestogens

• Long-course oral progestogens (≥3 weeks per cycle) are moderately effective 5
• Important: Short-course progestogens (≤14 days per cycle) are less effective and may not adequately control heavy bleeding 5

Essential Steps Before Starting Treatment

Rule Out Serious Causes

• Get a pregnancy test immediately – all reproductive-age women with abnormal bleeding must be tested 4, 1
• Perform pelvic ultrasound (transvaginal and transabdominal with Doppler) to identify fibroids, polyps, adenomyosis, or endometrial abnormalities 4
• Check thyroid and prolactin levels 4

Assess for Urgent Situations

• Seek urgent evaluation if bleeding soaks through a large pad or tampon every hour for 4+ consecutive hours 4, 1
• Check for signs of anemia (fatigue, dizziness, pale skin) 3

Special Considerations

If You're Taking Blood Thinners

• Approximately 70% of women on anticoagulation experience heavy menstrual bleeding 4
• The LNG-IUD is particularly effective for women on anticoagulation therapy 6
• Discuss with your doctor about reassessing the need for ongoing antiplatelet therapy 4
• Avoid NSAIDs and tranexamic acid if you have cardiovascular disease 4, 1

If You Have Uterine Fibroids

• First-line treatment includes NSAIDs and combined oral contraceptives 1
• The LNG-IUD effectively reduces bleeding even with fibroids present 5
• Tranexamic acid is a non-hormonal alternative 1

If Bleeding Persists Despite Treatment

• If bleeding continues or you find it unacceptable, return to discuss alternative methods 2
• May need referral to gynecologist if medical management fails 4
• Consider evaluation for underlying conditions like endometrial hyperplasia or malignancy 6

Treatment Algorithm Summary

1. Exclude pregnancy and serious pathology first (pregnancy test, ultrasound) 4, 1
2. Start NSAIDs during menstruation (5-7 days) if no cardiovascular contraindications 2, 1
3. If NSAIDs insufficient, consider LNG-IUD as most effective option 1, 5
4. Alternative: tranexamic acid if no clotting disorder history 1
5. Alternative: combined hormonal contraceptives as second-line hormonal option 5
6. Reassess after 3 months – bleeding patterns often improve with time 2

Common Pitfalls to Avoid

• Don't use short-course progestogens (less than 3 weeks) expecting significant improvement – they are minimally effective 5
• Don't ignore cardiovascular risk factors before starting NSAIDs or tranexamic acid 1
• Don't assume bleeding will resolve without addressing the underlying issue 6
• Don't delay evaluation if bleeding saturates pads hourly for 4+ hours 4