Management of Heavy Menstrual Bleeding

Initial Assessment

• The American College of Obstetricians and Gynecologists recommends evaluating the severity of bleeding, checking for signs of hemodynamic instability, and ruling out pregnancy in all reproductive-age women with abnormal uterine bleeding 3, 4
• Initial assessment should also include evaluation for underlying gynecological problems, such as sexually transmitted diseases, new pathologic uterine conditions, and medication interactions 3, 4, 5, 1

First-Line Treatment Options

• The American College of Obstetricians and Gynecologists recommends nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term treatment (5-7 days) during days of bleeding, which has been shown to reduce mean total menstrual blood loss 1, 2, 6
• Various NSAIDs, including indomethacin, mefenamic acid, flufenamic acid, and diclofenac sodium, have been studied and found to be effective in reducing heavy menstrual bleeding 5

Second-Line Treatment Options

• If bleeding persists, consider hormonal contraceptives, such as the levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95% 3, 7
• Tranexamic acid is a non-hormonal alternative that may reduce bleeding symptoms, but is contraindicated in women with active thromboembolic disease or history of thrombosis 1, 7

Special Considerations

• Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder, and if an underlying gynecological problem is found, treat the condition or refer for care 2, 6
• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful can improve treatment adherence 1, 5

Treatment Algorithm

• Start with NSAIDs for 5-7 days during days of bleeding, and if bleeding persists after 1-3 cycles, consider hormonal options or tranexamic acid 1, 2, 7
• If bleeding remains unacceptable despite medical treatment, counsel on alternative contraceptive methods or refer for further evaluation and possible surgical management 2, 6