What is the best management approach for a female patient presenting with acute heavy menstrual bleeding, defined by multiple clot-soaked pads within 12 hours, who desires to avoid long-term birth control?

Management of Acute Heavy Menstrual Bleeding Without Long-Term Contraception

For a patient with acute heavy menstrual bleeding (multiple clot-soaked pads within 12 hours) who refuses long-term birth control, initiate high-dose combined oral contraceptives (30-35 μg ethinyl estradiol) three times daily for 7 days to achieve hemostasis, then taper to once daily for 21 days, followed by tranexamic acid 1300 mg three times daily during future menses as maintenance therapy. 1, 2

Immediate Acute Management

High-dose hormonal therapy is the cornerstone of acute bleeding control:

• Start monophasic COCs containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate at three times daily dosing for 7 days to rapidly stabilize the endometrium and achieve hemostasis 1, 2
• After 7 days, taper to once daily for the remainder of a 21-day course 1
• This regimen induces regular shedding of a thinner endometrium and effectively reduces menstrual blood loss 1, 2

Add NSAIDs immediately for synergistic effect:

• Mefenamic acid 500 mg three times daily or celecoxib 200 mg daily for 5-7 days during bleeding episodes provides significant cessation of bleeding within 7 days 3, 1
• NSAIDs reduce menstrual blood loss acutely and can be used in combination with hormonal therapy 1, 4

Pre-Treatment Evaluation

Before initiating therapy, rule out life-threatening causes and contraindications:

• Exclude pregnancy with urine or serum β-hCG 1, 3
• Screen for sexually transmitted infections, particularly in reproductive-aged women 1, 3
• Assess for thrombotic risk factors (personal/family history of VTE, smoking, migraine with aura, age >35 with smoking) as COCs increase VTE risk three to fourfold 2, 1
• Consider underlying bleeding disorders if there is flooding, clots ≥1 inch diameter, or personal/family bleeding history 5

Non-Hormonal Maintenance Options

For ongoing management without long-term hormonal contraception, tranexamic acid is the preferred option:

• Tranexamic acid 1300 mg (two 650 mg tablets) three times daily during menses reduces menstrual blood loss by 20-60% 1, 6
• This is appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 1
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

NSAIDs as monotherapy for future cycles:

• Mefenamic acid, indomethacin, or diclofenac during menses reduces blood loss, though less effectively than tranexamic acid 1, 7
• This may be sufficient for women with marginally increased blood loss 8

Critical Counseling Points

Set realistic expectations about the acute treatment course:

• The initial 7-day high-dose COC regimen is not reliable contraception unless she has been using COCs continuously 2
• Unscheduled spotting or bleeding is common during the first 3-6 months of any hormonal therapy and is generally not harmful 1, 3
• After the acute 21-day COC course, she can transition to tranexamic acid for future cycles if she wishes to avoid ongoing hormonal therapy 1

When to Reassess

Re-evaluate if bleeding persists despite treatment:

• If heavy bleeding continues after 7 days of high-dose COCs plus NSAIDs, consider underlying structural pathology (fibroids, polyps, adenomyosis) or coagulopathy 3, 5
• Pelvic ultrasound and complete blood count with ferritin are indicated if bleeding does not respond to initial therapy 6, 5
• Up to 20% of women with HMB have an underlying inherited bleeding disorder, particularly if there is flooding, prolonged menses, or family history 6, 5

Common Pitfalls to Avoid

• Do not use short-course progestogens (≤14 days per cycle) for acute heavy bleeding—they are less effective than the options above 8
• Do not dismiss the need for acute high-dose therapy—standard once-daily COC dosing is insufficient for acute hemostasis 1, 2
• Do not overlook contraindications to estrogen therapy (active VTE, history of VTE without anticoagulation, migraine with aura, smoking age >35) 2, 1
• Avoid tranexamic acid in women with thrombotic risk as it is contraindicated in this population 1

Alternative Short-Term Options

If COCs are contraindicated due to thrombotic risk:

• High-dose oral progestin (medroxyprogesterone acetate) may be considered short-term for hemodynamically unstable women, though evidence is limited 2
• Cyclic oral medroxyprogesterone reduces menstrual blood loss by approximately 87% but requires at least 3 weeks per cycle to be effective 2, 8