Prolonged Menstrual Bleeding

Prolonged menstrual bleeding is a period lasting more than 8 days, whether or not the amount of blood lost is heavy. It results from anovulation, endometrial polyps, adenomyosis, fibroids, chronic endometritis, a caesarean scar niche, retained products after pregnancy, hormonal contraception, thyroid disease and bleeding disorders. It matters because the long loss causes iron deficiency anaemia, and persistent prolonged bleeding may signal endometrial hyperplasia or cancer.

• Risk factors: age above 40 years or within 2 years of menarche, obesity, polycystic ovary syndrome, previous caesarean section, intrauterine device, tamoxifen use, anticoagulants.
• Bleeding that lasts up to 8 days is normal; beyond that it is abnormal.
• Spotting at the end of a period for 3 or more days suggests a scar niche or polyp.

Women have periods lasting 9 or more days, with brown spotting at the end or continuous light bleeding, and sometimes clots, pelvic pain, tiredness and breathlessness from anaemia.

• Menstrual diary with bleeding of more than 8 days.
• Pallor, tachycardia; enlarged or tender uterus; goitre.
• Differential diagnosis: anovulatory bleeding, endometrial polyp, adenomyosis, fibroids, chronic endometritis, caesarean scar niche, retained products, miscarriage, endometrial hyperplasia or cancer, cervical lesion, hypothyroidism, bleeding disorder, contraceptive effect.
• Complications: iron deficiency anaemia, fatigue, reduced work and quality of life, infertility, hospital admission, endometrial hyperplasia.

The approach is to exclude pregnancy and structural or malignant disease and to measure haemoglobin.

• Urine or serum hCG; menstrual diary; speculum and bimanual examination.
• Full blood count, ferritin, thyroid stimulating hormone, coagulation screen and von Willebrand tests if bleeding has been heavy since menarche.
• High vaginal swab and chlamydia test; cervical screening if due.
• Transvaginal ultrasound for polyps, fibroids, adenomyosis, scar niche and endometrial thickness; endometrial sampling or hysteroscopy if age is 45 years or above, or bleeding persists.

The principle is to stop the bleeding, correct anaemia and treat the cause.

• Supportive: menstrual diary; iron rich diet; reassurance when no cause is found; avoid aspirin; stop smoking.
• Pharmacological: tranexamic acid 1 g oral 8-hourly for up to 5 days during bleeding (maximum 4 g daily); mefenamic acid 500 mg oral 8-hourly with food for up to 5 days; norethisterone 5 mg oral 8-hourly for 10 days to stop the bleeding; combined oral contraceptive pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms oral once daily for 21 days then 7 days free; levonorgestrel intrauterine system 52 mg for 5 years; doxycycline 100 mg oral 12-hourly for 14 days for chronic endometritis; ferrous sulphate 200 mg oral 12-hourly for 3 months; levothyroxine 50 micrograms oral once daily increased every 4 to 6 weeks for hypothyroidism.
• Procedures: hysteroscopic polypectomy or resection of submucous fibroid; evacuation of retained products; endometrial ablation after childbearing; uterine artery embolisation or myomectomy for fibroids; hysterectomy when other treatment fails.
• Special groups: women with renal impairment have tranexamic acid reduced to 15 mg/kg (usually 1 g) oral 12-hourly when creatinine is 120 to 249 micromol/L; women with previous clot avoid tranexamic acid and oestrogen and use progestogen-only methods or the levonorgestrel intrauterine system; women with bleeding disorders have haematology care.
• Red flags: haemoglobin below 8 g/dL, bleeding that soaks a pad every hour, syncope, endometrial thickness above 12 mm, postcoital bleeding, pelvic mass, weight loss.
• Follow-up: review at 3 months with diary and haemoglobin; ferritin at 3 months; endometrial assessment if no response by 6 months.