Treatment of Heavy Menstrual Bleeding

Initial Evaluation

The American College of Cardiology recommends excluding pregnancy in all reproductive-age women with abnormal bleeding 1
The Centers for Disease Control and Prevention suggests ruling out structural causes, such as fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 2, 3
Assess for coagulopathies if clinically indicated, as recommended by the Centers for Disease Control and Prevention 3
Review current medications, particularly anticoagulants or antiplatelet therapy that may contribute to bleeding, as advised by the American College of Cardiology 1

The American College of Cardiology recommends the levonorgestrel-releasing intrauterine device (LNG-IUD) as the most effective first-line treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95% 1
The Centers for Disease Control and Prevention suggests that NSAIDs are the recommended pharmacologic first-line treatment for women not using the LNG-IUD, with dosing of 5-7 days during menstruation only 2, 3, 4
The American Heart Association warns that NSAIDs should be avoided in women with cardiovascular disease due to increased MI and thrombosis risk 1, 4
The Centers for Disease Control and Prevention recommends considering tranexamic acid if NSAIDs are ineffective and there are no cardiovascular contraindications, but notes that it is contraindicated in women with cardiovascular disease due to thrombosis risk 1, 4

The American College of Cardiology advises careful assessment of cardiovascular and thrombotic risk factors when using combined hormonal contraceptives in perimenopausal women 1
The Centers for Disease Control and Prevention suggests that the LNG-IUD remains the most effective option for perimenopausal women and can be used through menopause 2, 5, 6

The Centers for Disease Control and Prevention recommends counseling on alternative methods and offering different medical options if bleeding persists despite optimal medical therapy 2, 5, 7
The American College of Cardiology suggests considering endometrial ablation as a conservative surgical option if medical management fails 1