Management of Menstrual Blood Loss

Medical Treatment

The Centers for Disease Control and Prevention recommends using a treatment for 5-7 days during menstruation and monitoring blood pressure during follow-up for women using combined hormonal contraceptives 1
The Centers for Disease Control and Prevention advises assessing treatment effectiveness after 3 months and considering changing to another medical treatment or proceeding to second-line options if bleeding persists or is unacceptable to the patient, with no routine follow-up visit required for most treatments, but advises patients to return if problems arise 1
Evaluation for underlying conditions should be performed before initiating symptomatic treatment, including blood typing and cross-matching if severe bleeding is present, as recommended by the World Health Organization, to ensure compatible blood transfusions 2, 1
Abnormal uterine bleeding should be classified using the PALM-COEIN system, which includes structural causes (PALM) and non-structural causes (COEIN), as recommended by the American Academy of Family Physicians and the American College of Family Physicians 3
Diagnostic tests should include pregnancy test, thyroid function tests, prolactin levels, endometrial biopsy (for women ≥35 years with recurrent anovulation or risk factors), and transvaginal ultrasonography or saline infusion sonohysterography for structural evaluation, as recommended by the American College of Radiology 3, 4

Combined hormonal contraceptives are effective for reducing menstrual blood loss, and can be used in extended or continuous regimens, providing a reduction in menstrual blood loss, as recommended by the American family physician guidelines 3, 1
Oral progestins are effective when given for 21 days per month, and can be an option when estrogen is contraindicated, although they are less effective than LNG-IUS or combined hormonal contraceptives, according to the American family physician guidelines 3, 1
Tranexamic acid provides a 26-60% reduction in menstrual blood loss, and should be taken only during menstruation, but is contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1, 5
Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce menstrual blood loss, but may increase cardiovascular risk with long-term use, and are recommended for short-term treatment (5-7 days) during menstruation 1

The following intrauterine systems are recognized for their efficacy in reducing menstrual blood loss:

Intrauterine System	Dosage	Efficacy
Mirena	20 μg/day	71-95% reduction in menstrual blood loss [5, 6]
Kyleena	14 μg/day	less documented evidence, potentially less effective menstrual bleeding control [5, 6]

The American College of Radiology recommends considering LNG-IUS as the first-line treatment for excessive menstrual bleeding, providing a 71-95% reduction in menstrual blood loss 1, 5, 6

If medical management fails after 3-6 months of adequate trial, consider endometrial ablation or hysterectomy as definitive treatment for refractory cases, as recommended by the American College of Radiology 7
Endometrial ablation may be considered for women with completed childbearing who fail medical management, offering a less invasive alternative to hysterectomy, with uterine preservation and fewer complications compared to hysterectomy 3, 6, 7
Hysterectomy is the definitive treatment for refractory cases, and should be considered when other treatments have failed or when significant intracavitary lesions are present, as stated by the American family physician and the American College of Radiology 3, 4