Management of Prolonged Menstrual Bleeding with Fatigue

Initial Urgent Evaluation

The American Heart Association recommends urgent evaluation of hemodynamic stability in patients with severe bleeding criteria, such as saturating a large towel every hour for at least 4 hours, which is equivalent to 3-4 soaked towels per hour for 3 weeks 1
The American College of Obstetricians and Gynecologists suggests that a pregnancy test (β-hCG) is mandatory in all women of reproductive age with abnormal uterine bleeding 1
Evaluation of thyroid function through TSH and prolactin levels is necessary to rule out ovulatory dysfunction 1
Ultrasonido transvaginal and transabdominal with Doppler is the first-line imaging study to identify structural causes (polyps, adenomyosis, leiomyomas, endometrial hyperplasia/malignancy) 1

The American College of Obstetricians and Gynecologists recommends ácido tranexámico as the most effective treatment for acute bleeding, reducing menstrual bleeding by 40-60%, but it is contraindicated in patients with a history of thromboembolism or active cardiovascular disease 1, 2
Non-steroidal anti-inflammatory drugs (NSAIDs), except aspirin, can reduce blood loss by 20-60% for 5-7 days during the bleeding episode, and should be used if ácido tranexámico is contraindicated 2, 3
Aspirin should be avoided as it can paradoxically increase bleeding 2

The American College of Obstetricians and Gynecologists suggests that the levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective long-term medical treatment, reducing menstrual blood loss by 71-95%, with efficacy comparable to endometrial ablation or hysterectomy 2

Urgent referral is recommended if there is failure of medical treatment after 3 months, endometrial biopsy showing hyperplasia or malignancy, endometrial thickness ≥4 mm in postmenopausal women, or persistent hemodynamic instability 1, 2

Patients with a personal or family history of bleeding (epistaxis, dental bleeding, easy bruising) or refractory bleeding to initial treatment should be referred to hematology for evaluation of hereditary bleeding disorders such as von Willebrand disease 4, 5
Anticoagulation therapy should be reevaluated and considered for suspension if appropriate, and the LNG-IUS is particularly useful in these patients 1, 2