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

Evaluation and First-Line Management of Heavy Menstrual Bleeding in Reproductive-Aged Women

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1, 2

Initial Assessment

Immediate Evaluation

• Test for pregnancy with β-hCG in all reproductive-age women before any further workup, regardless of contraceptive use or perceived risk 1, 3
• Assess hemodynamic stability; urgent evaluation is required when bleeding saturates a large pad or tampon hourly for at least 4 hours 1
• Perform speculum examination to exclude cervical or vaginal sources of bleeding 1, 3
• Conduct bimanual examination to assess uterine size, contour, mobility, and adnexal masses 1

Diagnostic Workup

• Order combined transabdominal and transvaginal ultrasound with Doppler as the first-line imaging study to identify structural causes including polyps, adenomyosis, leiomyomas, and endometrial hyperplasia/malignancy 1
• Obtain thyroid-stimulating hormone and prolactin levels to screen for endocrine contributors 1, 3
• Check complete blood count with platelets to evaluate for anemia and coagulopathy 1, 3
• Perform endometrial sampling in women ≥45 years or those with risk factors (obesity, diabetes, hypertension, unopposed estrogen exposure, Lynch syndrome, tamoxifen use) 1, 3

Classification Using PALM-COEIN System

The PALM-COEIN framework categorizes causes into structural and non-structural etiologies 1, 2:

Structural (PALM):

• Polyp (more common in women >40 years) 1
• Adenomyosis (frequently coexists with fibroids in women in their 40s, presents with dysmenorrhea and dyspareunia) 2, 3
• Leiomyoma/fibroids (most common structural cause in women <40 years) 1
• Malignancy and hyperplasia 1, 2

Non-structural (COEIN):

• Coagulopathy (up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder) 4
• Ovulatory dysfunction (common in perimenopause) 1, 3
• Endometrial disorders 1
• Iatrogenic (approximately 70% of women on anticoagulation experience heavy menstrual bleeding) 1, 3
• Not yet classified 1

First-Line Medical Management Algorithm

Primary Recommendation

Insert a levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) as the most effective first-line treatment 1, 2, 3. This device:

• Reduces menstrual blood loss by 71-95% 1, 2
• Has efficacy comparable to endometrial ablation 1, 2
• Is the only progestin IUD specifically evaluated for abnormal uterine bleeding 5, 2
• Works primarily at the endometrial level with minimal systemic absorption 5, 2

Alternative First-Line Options

For ovulatory dysfunction bleeding:

• Combined oral contraceptives (COCs) containing 30-35 μg ethinyl estradiol regulate the menstrual cycle and provide contraception 3
• Can be combined with NSAIDs to further reduce bleeding volume 2, 3

For cyclic heavy bleeding:

• Oral progestins administered for 21 days per month reduce menstrual blood loss by approximately 87% 5, 2
• Note: Cyclic progestogens do not significantly reduce bleeding in women who ovulate 6

Non-hormonal option:

• Tranexamic acid reduces menstrual blood loss by 20-60% and is useful when hormonal therapy is contraindicated 2, 3, 6
• NSAIDs modestly reduce menstrual bleeding and may be used adjunctively 2, 3

Special Populations and Critical Contraindications

Cardiovascular Disease or Post-SCAD Patients

Avoid NSAIDs and tranexamic acid in patients with cardiovascular disease or history of spontaneous coronary artery dissection due to increased risk of myocardial infarction and thrombosis 5, 1, 2. In these patients:

• The LNG-IUD becomes the strongly preferred option due to minimal systemic absorption 5, 2, 3
• Systemic hormonal therapy is relatively contraindicated and requires careful clinical judgment 5, 2

Anticoagulation Therapy

• Reassess the indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating treatment 5, 1
• Progestin-eluting IUDs are preferred due to minimal systemic absorption 5
• Approximately 70% of women on anticoagulation experience heavy menstrual bleeding 1, 3

When to Refer to Gynecology

Refer patients when 1, 3:

• Medical management fails after an adequate trial
• Endometrial sampling reveals hyperplasia or malignancy
• Postmenopausal bleeding with endometrial thickness ≥4 mm
• Bleeding persists despite therapy and focal lesions may have been missed

Surgical Options After Medical Failure

• Endometrial ablation offers a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 2, 3
• Hysterectomy provides definitive symptom resolution and significantly better health-related quality of life when medical treatment fails or is contraindicated 1, 2, 3

Common Pitfalls to Avoid

• Do not rely solely on endometrial biopsy to exclude focal lesions; saline-infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for uterine pathology 2, 3
• Never prescribe NSAIDs or tranexamic acid to women with cardiovascular disease without assessing thrombotic risk 5, 1, 2
• Always perform pregnancy testing even in patients using contraception 1, 3
• When prescribing progestogen therapy for fibroids, assess need for non-hormonal contraception because ovulation may still occur in up to 20% of patients 2
• Provide thorough informed consent for endometrial ablation regarding long-term complications including Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis 2