Management of Heavy Vaginal Bleeding in a 44-Year-Old Woman with Anemia
The most appropriate next step is mefenamic acid (Option B), as NSAIDs like mefenamic acid provide immediate reduction in menstrual blood loss by 20-60% and should be trialed for 5-7 days as first-line medical therapy before considering more invasive interventions. 1, 2
Rationale for NSAID Therapy First
NSAIDs are the recommended initial medical treatment for acute heavy menstrual bleeding, with mefenamic acid specifically cited as an effective agent that demonstrated statistically significant reductions in mean total menstrual blood loss in systematic reviews. 1, 2
This approach aligns with guideline recommendations that medical management should be trialed prior to pursuing more invasive therapies such as surgical interventions or device insertion. 1
The immediate goal is to reduce blood loss acutely while simultaneously evaluating for underlying pathology (pregnancy, infection, structural lesions like fibroids or polyps). 2
Why Other Options Are Less Appropriate
Hysterectomy (Option A)
- Hysterectomy is premature without first attempting medical management, as guidelines consistently recommend exhausting conservative options before definitive surgery. 1
- While hysterectomy may ultimately be appropriate for postmenopausal patients with negative endometrial evaluation and persistent symptoms, it should not be the initial step in a 44-year-old woman. 1
Hormonal IUD (Option C)
- The levonorgestrel-releasing IUD (LNG-IUS) is highly effective for heavy menstrual bleeding (86-97% reduction in menstrual blood loss) and can serve as an alternative to hysterectomy. 3, 4, 5, 6
- However, insertion during active heavy bleeding is problematic, and the device takes 3-6 months to achieve maximal effect on bleeding reduction. 1
- Unscheduled bleeding is common during the first 3-6 months after LNG-IUS insertion, which would not address the acute bleeding crisis. 1, 2
- The LNG-IUS is better suited as a second-line option after acute bleeding is controlled and underlying pathology is excluded. 5, 6
Dilatation and Curettage (Option D)
- D&C is primarily a diagnostic procedure to exclude endometrial pathology (hyperplasia, malignancy) rather than a therapeutic intervention for heavy bleeding. 2
- While it may provide temporary relief, bleeding typically recurs, making it less appropriate than medical management as an initial step.
- D&C would be indicated if there were specific concerns for endometrial pathology requiring tissue diagnosis, but this is not suggested by the clinical scenario.
Clinical Algorithm for Management
Immediate treatment: Start mefenamic acid 500 mg three times daily for 5-7 days during bleeding episodes. 1, 2
Concurrent evaluation: Rule out pregnancy (even in perimenopausal women), sexually transmitted infections, and structural lesions (fibroids, polyps). 1, 2
If bleeding persists beyond initial NSAID therapy: Consider adding hormonal treatment with combined oral contraceptives (30-35 μg ethinyl estradiol) for 10-20 days if medically eligible. 2
For ongoing management after acute control: Consider LNG-IUS insertion, which provides superior long-term reduction in menstrual blood loss compared to other medical therapies and can prevent future episodes. 5, 6
If medical management fails and bleeding remains unacceptable: Counsel on alternative methods including endometrial ablation or hysterectomy. 1
Important Caveats
Screen for contraindications to NSAIDs including active peptic ulcer disease, renal impairment, and bleeding disorders before prescribing. 2
Enhanced counseling improves adherence: Reassure the patient that initial medical management is appropriate and that bleeding irregularities with hormonal therapies are common in the first 3-6 months but generally not harmful. 1, 2
Address anemia concurrently: While managing the bleeding source, initiate iron supplementation to correct the anemia that has resulted from chronic blood loss.