How should I evaluate and manage a 39-year-old woman with acute menorrhagia (tampon saturated within two hours)?

Management of Acute Menorrhagia in a 39-Year-Old Woman

Begin with a levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line treatment, as it reduces menstrual blood loss by 71-96% and is the most effective medical therapy for heavy menstrual bleeding. 1

Immediate Assessment

Hemodynamic Stability and Anemia Evaluation

• Check vital signs immediately to assess for hemodynamic compromise from acute blood loss 1
• Obtain a complete blood count with red cell indices and platelet count to evaluate for iron deficiency anemia, which affects 20-25% of women with menorrhagia 1
• Measure serum ferritin if available, as menorrhagia is the most common cause of iron deficiency in reproductive-age women 1

Pregnancy and Structural Pathology Exclusion

• Perform a urine or serum hCG test to rule out pregnancy-related bleeding complications 2
• Conduct a pelvic examination to assess for cervical pathology and uterine size/contour 2
• Order transvaginal ultrasound as the first-line imaging modality to identify fibroids, polyps, or adenomyosis—the most common structural causes in this age group 3, 2

Coagulopathy Screening

• Assess for bleeding disorder risk factors: heavy bleeding since menarche, family history of bleeding disorders, easy bruising, or prolonged bleeding after dental procedures 4
• Up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder, particularly von Willebrand disease 4
• If screening suggests coagulopathy, obtain PT, aPTT, and von Willebrand factor studies 4

First-Line Medical Management

Levonorgestrel-Releasing Intrauterine System (LNG-IUS)

The LNG-IUS is the gold standard first-line treatment when contraception is acceptable or desired, with efficacy comparable to endometrial ablation or hysterectomy. 1

• Reduces menstrual blood loss by 71-96% within 3-6 months 1
• Approximately 50% of users develop amenorrhea or oligomenorrhea after 2 years 1
• Particularly beneficial in women with severe thrombocytopenia or coagulopathy 1
• Can be inserted even in the presence of heavy bleeding according to 2010 U.S. Medical Eligibility Criteria 5

Alternative First-Line Options

Combined oral contraceptives are the preferred alternative when LNG-IUS is declined or contraindicated, as they regularize cycles and significantly reduce bleeding compared to NSAIDs, antifibrinolytics, or oral progestins alone 1

Tranexamic acid 1000-1500 mg three times daily during menses is the optimal non-hormonal option, particularly when:

• Hormonal contraception is contraindicated 1
• Immediate pregnancy is desired 2
• Bleeding disorders or coagulopathies are present 1
• Reduces menstrual blood loss by 34-59% over 2-3 cycles 1

NSAIDs (mefenamic acid 500 mg three times daily during bleeding episodes) provide 20-35% reduction in menstrual blood loss but are less effective than other options 1

• Reserve for short-term use (5-7 days per cycle) 1
• Suitable for women refusing hormonal treatment or with irregular light bleeding on injectable contraception 1

Progestin-Only Options

• Oral progestins (norethindrone) may be useful in women with severe thrombocytopenia 1
• Critical caveat: Do not use depot medroxyprogesterone acetate (DMPA) in acute heavy bleeding, as it causes irregular bleeding and has 11-13 week irreversibility 1
• Limit progestin-only therapy to less than 6 months due to meningioma risk 1

Iron Replacement for Anemia

Initiate ferrous sulfate 200 mg three times daily to correct anemia and replenish iron stores. 1

• Add ascorbic acid (vitamin C) to improve iron absorption if response is insufficient 1
• Continue iron supplementation for 3 months after hemoglobin normalization to replenish stores 1
• Monitor hemoglobin and mean corpuscular volume (MCV) every 3 months for 1 year, then annually 1

When to Consider Imaging Beyond Ultrasound

MRI Indications

• Transvaginal ultrasound cannot completely visualize the endometrium due to large fibroids, adenomyosis, or patient body habitus 3
• MRI with diffusion-weighted imaging improves sensitivity and specificity for diagnosing uterine pathology, particularly endometrial cancer 3
• Consider MRI before uterine artery embolization to provide vascular road map 3

Hysteroscopy or Sonohysterography

• Second-line procedures when ultrasound suggests endometrial polyps or submucosal fibroids 2
• Hysteroscopy allows direct visualization and simultaneous biopsy or polypectomy 6

Endometrial Sampling Considerations

Endometrial biopsy is indicated in this 39-year-old if:

• She has risk factors for endometrial hyperplasia or cancer (obesity, diabetes, PCOS, unopposed estrogen exposure) 3
• Ultrasound shows thickened endometrium (>4 mm in this premenopausal woman with abnormal bleeding) 3
• Bleeding persists despite 3-6 months of appropriate medical therapy 1

Surgical Options if Medical Management Fails

Uterine Artery Embolization (UAE)

• Clinical success rate of 81-100% for menorrhagia 1
• 83% of women report symptom improvement at 3 months 1
• Important caveat: 20-25% experience symptom recurrence at 5-7 years 1
• Preserves the uterus but may affect future fertility 1

Endometrial Ablation

• Second-generation techniques (thermal balloon, microwave, radiofrequency) have greater long-term efficacy than oral medical treatment 2
• Low operative morbidity and can be performed as outpatient procedure 4
• Critical warning: Pregnancy after ablation carries significant risks; provide thorough contraception counseling 5

Hysterectomy

• Definitive treatment when medical therapies and conservative surgery have failed 4, 2
• Vaginal or laparoscopic approach preferred over abdominal 2
• Not recommended as first-line for functional bleeding 2

Follow-Up and Re-Evaluation

• Re-assess treatment efficacy at 3-6 months to determine if bleeding has improved to acceptable levels 1
• If hemoglobin and MCV cannot be maintained within normal ranges despite iron supplementation, further investigation is necessary 1
• Continue hemoglobin monitoring every 3 months for 1 year after anemia correction, then annually 1

Common Pitfalls to Avoid

• Do not use cyclic progestins (10-14 days per month) as primary treatment—they do not significantly reduce menstrual bleeding in ovulatory women 6
• Do not delay iron supplementation while waiting for definitive treatment; anemia significantly impairs quality of life 1
• Do not perform hysterectomy as first-line therapy without trial of medical management or conservative surgery 2
• Do not miss coagulopathy screening in women with lifelong heavy bleeding or family history, as 20% have inherited bleeding disorders 4
• Do not rely on patient's subjective assessment of blood loss; saturating a tampon in 2 hours indicates objective heavy bleeding requiring intervention 7, 6