Management of Heavy Vaginal Bleeding in a 44-Year-Old Woman
Start mefenamic acid 500 mg three times daily for 5–7 days as the most appropriate next step in management. 1
Rationale for NSAID Therapy as First-Line Treatment
Mefenamic acid reduces menstrual blood loss by 20–60% acutely and is recommended as the initial medical therapy before any invasive intervention. 1, 2 This approach prioritizes medical management over surgical or device-based options, which is the standard of care for hemodynamically stable patients with heavy vaginal bleeding. 1
Why Not the Other Options?
Hysterectomy (Option A) is premature and inappropriate without first exhausting conservative medical options. 1 Definitive surgery should be reserved for cases where medical therapy fails or is contraindicated, as it carries significant morbidity and eliminates future fertility. 1
Hormonal IUD insertion (Option C) is problematic during an active heavy bleeding episode and requires 3–6 months to achieve maximal effect. 1 While the levonorgestrel-releasing IUD can reduce menstrual blood loss by 86–97% long-term 1, 3, unscheduled bleeding is common during the first 3–6 months after placement, making it unsuitable for immediate control of acute bleeding. 1 The device is more appropriate as a second-line option after acute bleeding is controlled. 3, 4
Dilation and curettage (Option D) is primarily a diagnostic tool for endometrial pathology and does not provide durable control of heavy bleeding. 1 It is therefore less appropriate as an initial therapeutic step compared to medical management. 1
Immediate Clinical Actions
- Initiate mefenamic acid 500 mg three times daily for a 5–7 day course during the bleeding episode. 1, 2
- Concurrently evaluate for pregnancy (even in perimenopausal women), sexually transmitted infections, and structural lesions such as fibroids or polyps. 1, 5
- Rule out thyroid disorders and coagulopathy as underlying causes. 2
Escalation Strategy if NSAID Therapy Fails
If bleeding persists after the initial NSAID trial, add tranexamic acid for 5 days during menstruation, which provides an additional 20–60% reduction in menstrual blood loss. 2 Tranexamic acid is appropriate when immediate pregnancy is desired or hormonal treatment is contraindicated, though it should not be used in women with active thromboembolic disease or history/risk of thrombosis. 1
Consider a short course of combined oral contraceptives (30–35 μg ethinyl estradiol) for 10–20 days if the patient is medically eligible and bleeding continues despite NSAIDs. 1 This induces regular shedding of a thinner endometrium and provides effective control. 1
When medical management fails to achieve acceptable control after these steps, counsel the patient about definitive options including the levonorgestrel-releasing IUD (once acute bleeding is controlled), endometrial ablation, or hysterectomy. 1
Counseling Points
Enhanced patient counseling improves adherence to NSAID therapy and should include reassurance that irregular bleeding with hormonal treatments during the first 3–6 months is common and generally not harmful. 1, 5 This reduces discontinuation rates and improves patient satisfaction. 1
Regular follow-up is essential to assess treatment efficacy and adjust therapy as needed. 2 Patients should return if bleeding persists beyond the initial treatment period for re-evaluation of underlying gynecological problems. 5