How to Treat Prolonged or Heavy Menstrual Bleeding

Abnormal uterine bleeding—particularly prolonged or persistent menstrual bleeding, clinically termed menorrhagia or metrorrhagia—requires thorough evaluation to identify underlying causes and guide appropriate management. When menstrual periods last longer than seven days or involve heavy, continuous flow without clear cessation, it may signal conditions such as anovulatory cycles, uterine fibroids, endometrial polyps, adenomyosis, thyroid dysfunction, coagulopathies (e.g., von Willebrand disease), or, in perimenopausal or postmenopausal individuals, endometrial hyperplasia or malignancy.

Initial assessment should include a detailed menstrual history, physical examination—including pelvic exam—and targeted investigations: serum ferritin to assess for iron-deficiency anemia, thyroid-stimulating hormone (TSH), prolactin, and, when indicated, coagulation studies. Transvaginal ultrasound is first-line imaging to evaluate uterine morphology and endometrial thickness; endometrial biopsy or hysteroscopy with sampling may be warranted in patients over age 45, those with risk factors for endometrial cancer, or those unresponsive to initial therapy.

First-line medical management often includes combined hormonal contraceptives (oral, patch, or ring) or progestin-only regimens—such as oral norethindrone, levonorgestrel-releasing intrauterine system (LNG-IUS), or depot medroxyprogesterone acetate—to stabilize the endometrium and reduce bleeding. Tranexamic acid, an antifibrinolytic agent, is FDA-approved for reducing menstrual blood loss and may be used cyclically during menses. Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen can also modestly decrease flow and alleviate dysmenorrhea.

For patients refractory to medical therapy—or those with structural pathology such as large fibroids or polyps—surgical options include hysteroscopic polypectomy or myomectomy, endometrial ablation (in select cases where fertility is not desired), or, in severe or recurrent cases, hysterectomy. Shared decision-making, consideration of reproductive goals, comorbidities, and patient preferences are essential throughout the treatment pathway.