Management of Prolonged Menstrual Bleeding (≥ 23 days)

Initial Assessment

Exclude pregnancy, sexually transmitted infections, thyroid dysfunction, structural uterine pathology (e.g., polyps, fibroids, malignancy), medication interactions, and other underlying conditions before initiating therapy. [CDC 2024][1]
Pregnancy must be ruled out first in any woman presenting with prolonged bleeding. [CDC 2013][3]
When clinically indicated, test for sexually transmitted infections. [CDC 2024][1]
If symptoms suggest thyroid disease, obtain a thyroid‑stimulating hormone measurement. [CDC 2024][1]
Evaluate for new pathologic uterine conditions such as polyps, fibroids, or malignancy. [CDC 2024][5]
Review the patient’s current medication list for agents that may affect bleeding. [CDC 2013][3]

Administer non‑steroidal anti‑inflammatory drugs (NSAIDs) for 5–7 days during the bleeding episode; treatment can be repeated as needed. [CDC 2024][1]
NSAID options include ibuprofen, mefenamic acid 500 mg three times daily, or celecoxib. [CDC 2013][3]

Provide hormonal therapy for 10–20 days when bleeding persists or is heavy. [CDC 2024][1]
- Use low‑dose combined oral contraceptives if the patient is medically eligible. [CDC 2013][3]
- Estrogen alone is an alternative hormonal option. [CDC 2013][8]
Offer tranexamic acid for a 5‑day course, especially for heavy or prolonged bleeding. [CDC 2024][1]

Copper IUD users: NSAIDs for 5–7 days for any bleeding pattern. [CDC 2024][1]
Implant users: NSAIDs for 5–7 days for light bleeding; add hormonal therapy (10–20 days), tranexamic acid (5 days), or a selective estrogen‑receptor modulator such as tamoxifen (7–10 days) for heavy or prolonged bleeding. [CDC 2024][1]
Depot medroxyprogesterone acetate (DMPA) users: NSAIDs for 5–7 days for spotting or light bleeding. [CDC 2024][1]

If an appropriate trial of medical therapy fails, proceed with imaging (e.g., ultrasound) or hysteroscopic evaluation to identify possible structural lesions. [American Family Physician 2014][9]
Refer the patient when:
- Medical management is unsuccessful after a reasonable trial;
- There is suspicion of malignancy or significant structural pathology. [American Family Physician 2014][9]