What is the first‑line medication to treat heavy menstrual bleeding (menorrhagia) in an adult woman without contraindications?

First-Line Medication for Heavy Menstrual Bleeding

NSAIDs (nonsteroidal anti-inflammatory drugs) are the recommended first-line pharmacologic treatment for heavy menstrual bleeding, prescribed for 5-7 days during menstruation only. 1, 2

Why NSAIDs Are First-Line

• The CDC and ACOG both recommend NSAIDs as the initial medication for heavy menstrual bleeding, with demonstrated reductions in menstrual blood loss of 26-60% across multiple studies 1, 2
• Effective NSAIDs include mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium—all showing statistically significant reductions in blood loss 1, 2
• The treatment duration is limited to 5-7 days during active bleeding days only, not continuous use 1, 2
• NSAIDs are particularly effective for copper IUD-associated heavy bleeding 1

Critical Contraindications to Screen For

You must screen for cardiovascular disease before prescribing NSAIDs, as they are absolutely contraindicated in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis. 2

• Avoid aspirin entirely—it does not reduce bleeding and may actually increase blood loss 1, 2

Second-Line Options When NSAIDs Fail or Are Contraindicated

The hierarchy of second-line treatments in descending order of effectiveness:

1. Levonorgestrel-releasing IUD (LNG-IUD): Reduces menstrual blood loss by 71-95%, the most effective medical treatment available 1, 2, 3

   • Many women develop amenorrhea over time, which is often a desired outcome 1, 2
   • Can be used through menopause in perimenopausal women 2

2. Tranexamic acid: A nonhormonal alternative reducing menstrual blood loss by 34-60% 4, 5, 6

   • FDA-recommended dosing is 3.9-4 g per day for 4-5 days starting from the first day of menstruation 7, 5
   • Absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 7, 2
   • Do not combine with hormonal contraceptives due to increased thrombotic risk 7

3. Combined hormonal contraceptives (oral or transvaginal): Effective for reducing bleeding but less so than LNG-IUD 2, 3

Essential Initial Assessment Before Treatment

• Rule out pregnancy with beta-hCG in all reproductive-age women 2
• Assess for structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 2
• Evaluate for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 2

Special Consideration for Fibroid-Related Bleeding

For women with uterine fibroids causing heavy bleeding, the same first-line approach applies: NSAIDs and estrogen-progestin oral contraceptive pills 4, 2. Tranexamic acid remains a nonhormonal alternative 4.

Common Pitfalls to Avoid

• Do not prescribe NSAIDs for continuous use—only during the 5-7 days of active bleeding 1, 2
• Do not use aspirin for heavy menstrual bleeding 1, 2
• Do not prescribe tranexamic acid without screening for cardiovascular disease and thrombotic risk 7, 2
• Do not assume short-course luteal phase progestogens (≤14 days per cycle) will be effective—they provide less impressive reductions in blood loss 3