How to manage a female patient with menorrhagia (heavy menstrual bleeding) and abundant blood clots during menstruation?

Management of Heavy Menstrual Bleeding with Blood Clots

Start with NSAIDs for 5-7 days during menstruation as first-line treatment, but if this fails or the patient has cardiovascular disease, immediately switch to the levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95%. 1

Immediate Assessment Required

Before initiating any treatment, you must:

• Rule out pregnancy with a β-hCG test in all reproductive-age women 2, 1
• Assess hemodynamic stability - urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
• Perform transvaginal ultrasound with Doppler to identify structural causes (fibroids, polyps, adenomyosis, endometrial hyperplasia/malignancy) 2
• Check for coagulopathy - up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder, and approximately 70% of women on anticoagulation experience this symptom 1, 2
• Obtain thyroid-stimulating hormone and prolactin levels to evaluate for ovulatory dysfunction 2

The presence of blood clots ≥1 inch diameter, "flooding" (changing pad/tampon more than hourly), and low ferritin strongly predict heavy menstrual bleeding and warrant aggressive management 3.

First-Line Medical Treatment

NSAIDs are the recommended first-line pharmacologic treatment, prescribed for 5-7 days during menstruation only 1:

• Mefenamic acid, naproxen, indomethacin, flufenamic acid, or diclofenac sodium all demonstrate statistically significant reductions in menstrual blood loss by 20-60% 1, 4
• Never use aspirin - it does not reduce bleeding and may actually increase blood loss 1, 4
• Critical contraindication: NSAIDs must be avoided in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 1

Second-Line Treatment (Most Effective)

The LNG-IUD is the most effective medical treatment for heavy menstrual bleeding, reducing blood loss by 71-95% 1:

• Over time, many women experience only light menstrual bleeding or amenorrhea 1
• Can be used through menopause in perimenopausal women 1
• Effectiveness is comparable to endometrial ablation or hysterectomy 2
• Particularly useful in women with severe thrombocytopenia or those on anticoagulation therapy 5, 4

Alternative Medical Options

Tranexamic acid reduces menstrual blood loss by approximately 80 mL per cycle (40-60% reduction) 1, 4:

• Absolute contraindications: active thromboembolic disease, history of thrombosis, or cardiovascular disease 1
• More expensive than other options 4

Combined oral contraceptives can be considered for women desiring contraception 4:

• Particularly effective for anovulatory bleeding 4
• Higher thrombotic risk than standard hormone replacement therapy 1

Treatment Algorithm Based on Specific Scenarios

If Patient Has Cardiovascular Disease:

• Avoid NSAIDs and tranexamic acid completely 1
• Use LNG-IUD as first-line treatment 1

If Patient Is on Anticoagulation:

• Reassess indication for ongoing antiplatelet therapy and consider discontinuation if appropriate 2
• LNG-IUD is preferred as it reduces blood loss by 71-95% 4

If Patient Has Uterine Fibroids:

• First-line: NSAIDs and estrogen-progestin oral contraceptive pills 1
• Alternative: Tranexamic acid 1
• Second-line: GnRH agonists or antagonists to reduce both bleeding and tumor volume 1

When to Refer to Gynecologist

Refer immediately if 2:

• Failed medical management
• Endometrial sampling shows hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm
• Persistent bleeding despite treatment requires re-evaluation for underlying pathology 4

Common Pitfalls to Avoid

• Do not assume bleeding will resolve on its own without addressing the underlying issue 1
• Do not overlook cardiovascular risk factors before initiating NSAID or tranexamic acid therapy 1
• Do not dismiss bleeding in the first 3-6 months of IUD use as this is common and generally not harmful, but persistent bleeding requires evaluation 4
• Enhanced counseling about expected bleeding patterns improves treatment adherence 1