What is the appropriate evaluation and management for a reproductive‑age woman presenting with heavy menstrual bleeding?

Heavy Menstrual Bleeding: Diagnosis and Management

Initial Assessment

All reproductive-age women presenting with heavy menstrual bleeding must first undergo pregnancy testing with β-hCG to rule out pregnancy-related causes. 1, 2

Defining Heavy Menstrual Bleeding

• Heavy menstrual bleeding is defined as excessive blood loss (>80 mL per cycle) that interferes with physical, emotional, or social quality of life 3
• Clinically predictive features include clots ≥1 inch diameter, "flooding" (changing pad/tampon more frequently than hourly), low ferritin, and bleeding lasting >8 days 4, 5
• Urgent evaluation is warranted when bleeding saturates a large pad or tampon hourly for at least 4 hours 1

Physical Examination Priorities

• Assess hemodynamic stability with orthostatic blood pressure and pulse measurements 6
• Perform speculum examination to visualize cervix and vagina, excluding cervical or vaginal bleeding sources 1
• Conduct bimanual examination to assess uterine size, contour, mobility, and adnexal masses 1
• Palpate abdomen for enlarged uterus or masses 1

Essential Laboratory Workup

• Complete blood count with platelets to assess for anemia 1
• Thyroid-stimulating hormone and prolactin levels 1
• Coagulation studies if personal or family history of bleeding suggests inherited bleeding disorder—up to 20% of women with heavy menstrual bleeding have an underlying coagulopathy 3, 6
• Serum ferritin to assess iron stores 6

Diagnostic Imaging

Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study for identifying structural causes. 1

• Transvaginal ultrasound evaluates for polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1
• In postmenopausal women, endometrial thickness <4 mm has nearly 100% negative predictive value for cancer 1
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine pathology, distinguishing leiomyomas from polyps with 97% accuracy 1
• MRI pelvis should be considered when ultrasound incompletely visualizes the uterus or findings are indeterminate 1

Classification Using PALM-COEIN System

The PALM-COEIN classification categorizes causes as structural (PALM) versus non-structural (COEIN): 1, 7

Structural Causes (PALM):

• Polyp—common in women >40 years 1
• Adenomyosis—frequent in premenopausal women in their 40s, often with dysmenorrhea and dyspareunia 1, 7
• Leiomyoma (fibroids)—most common structural cause in women <40 years 1
• Malignancy and hyperplasia—most serious etiology, main focus in postmenopausal women 1

Non-Structural Causes (COEIN):

• Coagulopathy—affects ~90% of women with underlying bleeding disorders 4
• Ovulatory dysfunction—causes irregular, heavy bleeding 1
• Endometrial—primary endometrial disorders with molecular deficiencies in hemostasis regulation 1
• Iatrogenic—~70% of women on anticoagulation experience heavy menstrual bleeding; oral anticoagulants cause abnormal bleeding in 9-14% of reproductive-age women 1, 4
• Not yet classified 1

Medical Management Algorithm

First-Line Treatment for Most Patients

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 7, 2, 8

• Over time, many women experience only light bleeding or amenorrhea 2
• Can be used through menopause in perimenopausal women 2
• Preferred option in women with cardiovascular disease due to minimal systemic absorption 7, 2

Alternative First-Line Options

NSAIDs (excluding aspirin) for 5-7 days during menstruation only:

• Mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium demonstrate statistically significant reductions in menstrual blood loss 2
• Critical contraindication: Must avoid in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 2
• Aspirin does not reduce bleeding and may increase blood loss 2

Tranexamic acid (non-hormonal antifibrinolytic):

• Reduces menstrual blood loss by 34-60% when taken for 4-5 days beginning on first day of menses 2, 3
• Absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 2

Second-Line Hormonal Options

• Combined hormonal contraceptives (oral or transvaginal) are effective for ovulatory dysfunction bleeding and can be combined with NSAIDs 7, 8
• Oral progestins administered for 21 days per month reduce menstrual blood loss in women with cyclic heavy bleeding 7
• Long-course oral progestogens (≥3 weeks per cycle) are more effective than short-course (≤14 days) 8

Special Scenario: Fibroids with Heavy Bleeding

• First-line: NSAIDs plus estrogen-progestin oral contraceptives 2
• Tranexamic acid serves as effective non-hormonal alternative 2
• Second-line: GnRH agonists (parenteral) or GnRH antagonists (oral) reduce bleeding and tumor volume 2
• Ulipristal acetate is FDA-approved for preoperative fibroid treatment 3

Critical Considerations for Special Populations

Patients on Anticoagulation

• Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate 1
• Progestin-eluting IUDs preferred due to minimal systemic absorption 7
• Avoid NSAIDs and tranexamic acid due to thrombotic risk 1, 7

Patients with Cardiovascular Disease

• Levonorgestrel-releasing IUD becomes the preferred option 7, 2
• NSAIDs and tranexamic acid are contraindicated 1, 7, 2
• Hormonal therapy is relatively contraindicated despite being first-line for most cases 7

Adolescents with Heavy Menstrual Bleeding

• Assessment must include evaluation for anemia (including serum ferritin), endocrine disorders causing anovulation, and bleeding disorders 6
• First-line approach to acute bleeding is medical management; surgery reserved for non-responders 6
• Antifibrinolytics (tranexamic acid or aminocaproic acid) in oral or IV form may stop acute bleeding 6

When to Refer to Gynecology

Refer patients with: 1

• Failed medical management
• Endometrial sampling showing hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm

Surgical Management

Indications for Surgical Intervention

• If bleeding persists despite medical therapy, hysteroscopy allows visualization of endometrial cavity and diagnosis of focal lesions possibly missed by endometrial sampling 7

Endometrial ablation:

• Less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 7
• Long-term complications include postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis—thorough informed consent required 7

Hysterectomy:

• Definitive treatment when medical management fails or is contraindicated 7
• Provides complete resolution of symptoms and significantly better health-related quality of life compared to other therapies 1
• Most appropriate for postmenopausal women with symptomatic fibroids 7

Common Pitfalls to Avoid

• Do not use endometrial biopsy alone to rule out focal lesions—it has variable sensitivity; saline infusion sonohysterography has superior sensitivity and negative predictive value 7
• Do not assume bleeding on progesterone therapy will resolve without addressing underlying issue—consider switching to LNG-IUD or adding combined hormonal contraceptives 2
• Do not prescribe NSAIDs or tranexamic acid without screening for cardiovascular risk factors and thromboembolic history 2
• Enhanced counseling about expected bleeding patterns improves treatment adherence, particularly with hormonal therapies 2