What is the appropriate work‑up and treatment for a 40‑year‑old woman with a one‑year history of heavier menstrual bleeding, premenstrual headaches, regular 24‑day cycles, and night sweats?

Work-Up and Treatment for Heavy Menstrual Bleeding with Premenstrual Headaches and Night Sweats

Start with NSAIDs for 5-7 days during menstruation as first-line treatment while simultaneously pursuing diagnostic evaluation with pregnancy test, TSH/prolactin, and transvaginal ultrasound to rule out structural causes and perimenopause. 1, 2

Immediate Diagnostic Work-Up

Essential Laboratory Tests

• Pregnancy test (β-hCG) – mandatory in all reproductive-age women with abnormal bleeding, even with regular cycles 2
• TSH and prolactin levels – to evaluate for thyroid dysfunction and hyperprolactinemia as causes of menstrual irregularity and night sweats 2
• FSH level – consider checking given the constellation of night sweats, shortened cycle (24 days), and age 40, which raises concern for perimenopause 2
• Complete blood count – to assess for anemia from chronic blood loss 2
• Coagulation screening – if there is personal or family history of bleeding disorders, as up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 1, 3

Imaging Studies

• Combined transabdominal and transvaginal ultrasound with Doppler is the first-line imaging study to identify structural causes including fibroids, polyps, adenomyosis, and endometrial pathology 2
• At age 40, endometrial polyps become increasingly common as a cause of heavy bleeding, while fibroids remain prevalent 2, 4

Physical Examination Priorities

• Abdominal examination to assess for enlarged uterus or masses 2
• Speculum examination to exclude cervical or vaginal sources of bleeding 2
• Bimanual examination to assess uterine size, contour, mobility, and adnexal masses 2

First-Line Medical Treatment

NSAIDs as Initial Therapy

• Prescribe mefenamic acid or naproxen for 5-7 days during menstruation only – this is the recommended first-line pharmacologic treatment, reducing menstrual blood loss significantly 1, 5
• Treatment duration must be limited to active bleeding days only 1
• Avoid aspirin as it does not reduce bleeding and may increase blood loss 1
• Screen for cardiovascular disease before initiating NSAIDs – they are contraindicated in women with cardiovascular disease due to increased MI and thrombosis risk 1, 2

Addressing Premenstrual Headaches

• NSAIDs taken during menstruation will also address premenstrual headaches through prostaglandin inhibition 1
• The regular 24-day cycle suggests ovulatory cycles, making hormonal fluctuations a likely contributor to premenstrual symptoms 2

Second-Line Treatment Options

If NSAIDs Fail or Are Contraindicated

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment for heavy menstrual bleeding, reducing blood loss by 71-95%. 1, 5

• The LNG-IUD can be used through menopause in perimenopausal women, making it ideal for this 40-year-old patient 1
• Over time, many women experience only light bleeding or amenorrhea 1
• It provides contraception while treating bleeding 5
• Minimal systemic hormone absorption makes it suitable when systemic exposure is undesirable 2

Alternative Second-Line Options

• Tranexamic acid (non-hormonal) reduces menstrual blood loss by approximately 34-60% when taken for 4-5 days starting on day 1 of menses 1, 3
• Absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease 1
• Cyclic oral progestins (21 days per month) reduce bleeding by approximately 87% 2, 6
• Combined hormonal contraceptives are effective but have higher thrombotic risk than standard HRT 1

Addressing Night Sweats

Perimenopause Evaluation

• Night sweats at age 40 with a shortened cycle (24 days) and heavy bleeding suggest possible perimenopause 2
• Check FSH level to assess ovarian reserve 2
• If perimenopausal, the LNG-IUD becomes particularly attractive as it can be continued through menopause 1

Rule Out Other Causes

• TSH to exclude hyperthyroidism 2
• Consider other systemic causes if hormonal evaluation is normal 2

Critical Pitfalls to Avoid

• Never assume bleeding will resolve without addressing the underlying issue 1
• Do not skip pregnancy testing even with regular cycles – this is mandatory 2
• Do not prescribe NSAIDs or tranexamic acid without screening for cardiovascular disease – both increase MI and thrombosis risk 1, 2
• Do not overlook structural causes – at age 40, polyps and fibroids are common and require imaging evaluation 2, 4
• Do not dismiss the 24-day cycle as "normal" – this shortened cycle combined with night sweats warrants perimenopause evaluation 2

Treatment Algorithm Summary

1. Immediate: Pregnancy test, TSH, prolactin, FSH, CBC 2
2. Imaging: Transvaginal ultrasound with Doppler 2
3. First-line treatment: NSAIDs (mefenamic acid or naproxen) for 5-7 days during menses 1, 5
4. If NSAIDs fail or contraindicated: LNG-IUD (preferred given age and potential perimenopause) 1, 5
5. Non-hormonal alternative: Tranexamic acid if no cardiovascular contraindications 1
6. Referral to gynecology: If medical management fails, endometrial sampling shows hyperplasia/malignancy, or imaging reveals significant structural pathology 2