# Heavy menstrual bleeding - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - Endocrine System Drugs 2024, norethisterone (norethindrone) monograph (endocrine.pdf page index 125, printed p112) · Mefenamic Acid 500 mg film-coated Tablets SmPC sections 4.2 and 4.3 (eMC product 12503) · Mikes BA, Vadakekut ES, Sparzak PB. Abnormal Uterine Bleeding. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Updated 2025 Feb 21. Bookshelf ID: NBK532913; PMID: 30422508. · Mirena 20 micrograms/24 hours intrauterine delivery system SmPC (eMC product 1132) · NICE Guideline NG88: Heavy menstrual bleeding: assessment and management 2018 · Tranexamic Acid 500 mg Tablets SmPC section 4.2 (eMC product 14622) - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Endocrine System Drugs 2024, norethisterone (norethindrone) monograph (endocrine.pdf page index 125, printed p112) - Mirena 20 micrograms/24 hours intrauterine delivery system SmPC (eMC product 1132) - SmPC section 4.2, https://www.medicines.org.uk/emc/product/12503/smpc - SmPC section 4.2, https://www.medicines.org.uk/emc/product/14622/smpc - Mikes BA, Vadakekut ES, Sparzak PB. Abnormal Uterine Bleeding. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Updated 2025 Feb 21. Bookshelf ID: NBK532913; PMID: 30422508. ## Treatment metadata - Tranexamic acid — 500 mg — oral.solid - Mefenamic acid — 500 mg — oral.solid - Levonorgestrel(intrauterine system, LNG-IUS) — 0.02 mg — vaginal - Norethisterone — 5 mg — oral.solid ## Complete treatment card ```text HEAVY MENSTRUAL BLEEDING Sources: Egyptian National Drug Formulary - Endocrine System Drugs 2024, norethisterone (norethindrone) monograph (endocrine.pdf page index 125, printed p112) · Mefenamic Acid 500 mg film-coated Tablets SmPC sections 4.2 and 4.3 (eMC product 12503) · Mikes BA, Vadakekut ES, Sparzak PB. Abnormal Uterine Bleeding. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Updated 2025 Feb 21. Bookshelf ID: NBK532913; PMID: 30422508. · Mirena 20 micrograms/24 hours intrauterine delivery system SmPC (eMC product 1132) · NICE Guideline NG88: Heavy menstrual bleeding: assessment and management 2018 · Tranexamic Acid 500 mg Tablets SmPC section 4.2 (eMC product 14622) Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (8) - Heavy flow means more than 80 mL a period; 5 to 80 mL is normal and under 5 mL is light - Volume cannot be measured in clinic, so ask how often pads or tampons are changed by day, about clots and their size, changing overnight, activities disrupted, and a flooding sensation [abnormal uterine bleeding · heavy periods] - Cycle frequency is graded as frequent, normal at 24 to 38 days, infrequent, or absent - A regular cycle varies by only about 2 to 7 days - Ask separately about bleeding between periods and after intercourse [abnormal uterine bleeding] - Associated features: bowel or bladder symptoms, pain, discharge, losing weight, and pointers to anaemia, a clotting problem or endocrine disease [anaemia · weight loss] - Age at first period and the date of the last period anchor the menstrual history - Family history of clotting disorders, cancer or endocrine disease is relevant SIGNS - what you find (7) - First check for instability: a drop in blood pressure on standing, or a fast pulse - Skin clues to anaemia or a clotting disorder: pallor, petechiae and bruising [anaemia · bruising · pallor · petechiae] - In adolescents, Tanner staging confirms the bleeding fits sexual maturity, stage III or above [bleeding] - Feel the thyroid for enlargement or tenderness - Excess or oddly distributed hair, an enlarged clitoris and acne suggest excess androgen [acne] - A rounded face, altered fat distribution and stretch marks suggest Cushing syndrome [stretch marks] - Palpate the abdomen for a pelvic or abdominal mass [abdominal mass · pelvic mass] TESTS (12) - Every woman of reproductive age needs a pregnancy test, urine or blood, plus a full blood count for anaemia and low platelets - Speculum and bimanual examination, with a smear and swabs for gonorrhoea and chlamydia plus wet prep when indicated - Thyroid function when there are thyroid symptoms or when no cause has emerged - Prolactin, androgens and oestrogen only where endocrine trouble is clinically suspected, such as anovulation or high prolactin - First-line clotting screen: platelet count, prothrombin time and the partial thromboplastin time, all of which can be normal in von Willebrand disease - Assess for a bleeding disorder when periods run 7 days with gushes or soaking through in 2 hours or less, when anaemia has been treated, with a family history, or after heavy bleeding at dental work, delivery, miscarriage or surgery - Check ferritin for iron stores; low means iron deficiency, but a normal value does not exclude anaemia when there is inflammation - Group and crossmatch when acute heavy bleeding has made the patient unstable - Image when the bimanual examination is abnormal or symptoms persist after first treatment; in adolescents not routinely unless treatment fails - Ultrasound, transvaginal or transabdominal, comes first and finds polyps, adenomyosis and fibroids; the abdominal route may suit adolescents better - MRI is kept for when ultrasound falls short, as with complex anatomy, fibroids or adenomyosis, and diffusion imaging helps separate benign from malignant - Sample the endometrium at 45 and over, and in younger women with persistent bleeding, unopposed oestrogen exposure or failed treatment; persisting symptoms after a normal biopsy need hysteroscopy IF NOT THIS - what else fits (8) - Any bleeding from the urinary or bowel tract can imitate uterine bleeding and has to be excluded - Vulva: benign growths or cancer - Vagina: benign growths, sexually transmitted infection, vaginitis, cancer, injury or a foreign body - Cervix: benign growths, sexually transmitted infection or cancer - Tubes and ovaries: pelvic inflammatory disease or cancer - Urinary tract: infection or cancer - Pregnancy and its complications: intrauterine pregnancy, miscarriage, ectopic pregnancy, placenta praevia - Causes arising in the body of the uterus are grouped under the PALM-COEIN headings Source StatPearls "Abnormal Uterine Bleeding" - disease-level clinical article Status traced to the source above Rx: Non-hormonal | If long-term treatment is wanted | Main treatment NON-HORMONAL - choose one 1. TRANEXAMIC ACID [1st line] Adult 1000 mg (2 tabs) PO TID during menstruation (max 4 g/day, up to 4 days). x up to 4 days per cycle; continue cycle-to-cycle for as long as it remains beneficial Peds 25 mg/kg per dose (data on efficacy, posology and safety for these indications are limited). Choice Alternatives among the non-hormonal options. Tranexamic acid is NG88's first-line non- hormonal treatment; mefenamic acid is the alternative when pain is the dominant complaint. Source SmPC section 4.2, https://www.medicines.org.uk/emc/product/14622/smpc Why Same NG88 first-line non-hormonal dose used under uterine-fibroids, offered here for heavy menstrual bleeding with no identified pathology, fibroids under 3 cm, or suspected/diagnosed adenomyosis. NG88 1.5.1 asks the prescriber to weigh the presence of fibroids, polyps, endometrial pathology or adenomyosis when agreeing treatment, and 1.5.2 scopes this first pharmacological pathway to those groups. A physician who has already diagnosed larger fibroids or other pathology should use the fibroid-specific entry instead; one who has not, or has adenomyosis, can start here. Caution Any postmenopausal bleeding (more than 12 months after the last period) is a different pathway - refer urgently via the suspected cancer pathway (routinely from age 55) rather than managing it as heavy menstrual bleeding. Check a full blood count in all women with heavy menstrual bleeding; treat confirmed iron deficiency using the iron-deficiency-anemia entry rather than dosing iron here. Contraindicated in active thromboembolic disease (DVT, PE) or history of venous/arterial thrombosis. Refer to gynaecology for intermenstrual or postcoital bleeding, a palpable pelvic mass, or bleeding that has not improved after 3 cycles of treatment. Contraindicated in severe renal impairment (risk of accumulation) and in patients with a history of convulsions. Egypt TREXAM 500 MG 20 TABS. MEMPHIS 24.00 EGP (1.20/unit) TRANEX 500 MG 30 TABS. EGPI > ABBOTT 117.00 EGP (3.90/unit) KAPRON 500 MG 20 F.C.TABS. AMOUN 110.00 EGP (5.50/unit) SAVIBLEED 500 MG 20 F.C.TABS. MARCYRL PHARM... 110.00 EGP (5.50/unit) 2. MEFENAMIC ACID [1st line] Adult 500 mg PO TID with or after food. Peds Children <12 years: use mefenamic acid suspension (50 mg/5 ml). Source SmPC section 4.2, https://www.medicines.org.uk/emc/product/12503/smpc Why Listed as a standalone first-line option, not only as the pain-relief add-on to tranexamic acid that it is under uterine-fibroids - NG88 offers tranexamic acid and an NSAID as independent choices, usable alone or together depending on whether pain is also a problem. Caution Discontinue immediately if diarrhoea develops (unique to mefenamic acid); avoid in active inflammatory bowel disease. Take with or after food to minimise gastric irritation. Avoid in active peptic ulcer disease, NSAID-induced asthma, or severe renal/hepatic impairment. Also treats the pain of dysmenorrhoea, so a reasonable first choice when heavy bleeding and cramping coexist; can be combined with tranexamic acid. CONTRAINDICATED in inflammatory bowel disease, in active or recurrent peptic ulcer or GI haemorrhage, and in severe renal failure. Maximum 1500 mg a day. Contraindicated in severe heart failure and during the last trimester of pregnancy. Egypt PONAGIC FORTE 500MG 10 F.C. TAB. RAMEDA 3.00 EGP (0.30/unit) MEFRONIL 500 MG 30 TABS. EL NILE. 14.25 EGP (0.47/unit) FAROSTAN FORTE 500MG 10 TAB. PHAROPHARMA 5.00 EGP (0.50/unit) MAFEPAIN 500MG 10 F.C. TAB. SPIMACO > EIMC 6.00 EGP (0.60/unit) MEFENAM 500MG 20 CAPS. JEDCO INT. CO... 14.00 EGP (0.70/unit) PONSTAN FORTE 500MG 20 F.C. TABS. PFIZER 14.00 EGP (0.70/unit) PONOFORTE 500MG 20 CAPS. UNIPHARMA 30.00 EGP (1.50/unit) IF LONG-TERM TREATMENT IS WANTED 3. LEVONORGESTREL(INTRAUTERINE SYSTEM, LNG-IUS) [1st line] Adult Levonorgestrel-releasing intrauterine system, 52 mg reservoir (releasing approximately 20 mcg/24h initially), fitted by a trained clinician within 7 days of the onset of menstruation x up to 5 years before replacement is needed for this indication (confirm against the current product licence) Peds Can be offered to adolescents per gynaecology/FSRH guidance; fitting in a younger or nulliparous adolescent may need general anaesthesia and specialist referral - arrange via gynaecology rather than fitting in primary care. Source Mirena 20 micrograms/24 hours intrauterine delivery system SmPC (eMC product 1132) Why NG88's actual first-choice option when longer-term treatment is wanted and hormonal contraception is acceptable. It does not appear under uterine-fibroids or primary- dysmenorrhoea, which list oral drugs only. It has the same first-line status for bleeding caused by adenomyosis, which is why adenomyosis is a synonym on this presentation-level entry rather than a separate page. strength_mg is recorded as 0.02 (the 20 mcg/24h release rate the Egyptian register's own strength parser reads from the product name), not the 52 mg total reservoir content stated in the dose above - recording the release-rate figure is what lets this treatment match the real Egyptian product as an exact strength instead of a false mismatch. Caution Intrauterine, not intravaginal. The form is recorded as vaginal because that is the route the Egyptian register files it under and it is what finds the product; the device is fitted into the uterine cavity by someone trained to do it. Fitting requires a trained clinician - refer to gynaecology or a family planning clinic if fitting is not available on site. Frequent spotting or light bleeding is common in the first 3-6 months; counsel before fitting so it is not mistaken for treatment failure. Investigate intermenstrual or postcoital bleeding, a palpable pelvic mass, and any postmenopausal bleeding BEFORE fitting - these need referral, not empirical treatment. Avoid in current pelvic infection, unexplained genital tract bleeding pending investigation, or current breast cancer. Egypt MIRENA INTRAUTERINE DELIVERY SYSTEM 20MCG/24 HRS BAYER SCHERING > BAYER ... 1911.00 EGP -> ? different route - not vaginal MAIN TREATMENT 4. NORETHISTERONE [2nd line] Adult Acute bleed: 20 mg by mouth three times daily for 7 days (StatPearls, Abnormal Uterine Bleeding NBK532913, acute AUB progestin-only option). The Egyptian National Drug Formulary gives 5 mg by mouth three times daily for 10 days for the same indication, with bleeding usually stopping within 48 hours. Then, to prevent recurrence: 5 mg by mouth twice daily from day 19 to day 26 of each of the next two cycles (Egyptian National Drug Formulary). x 7 days for the acute course (StatPearls) or 10 days (Egyptian formulary), then the day 19 to day 26 course in each of the two following cycles Peds The formulary gives adult dosing only; no paediatric or adolescent dose is stated in this monograph. Source StatPearls, Abnormal Uterine Bleeding (NBK532913), acute AUB progestin-only option (lead); Egyptian National Drug Formulary - Endocrine System Drugs 2024, norethisterone (norethindrone) monograph (endocrine.pdf page index 125, printed p112) Why Same regimen used under uterine-fibroids - the acute stop-the-bleed course printed above, then 5 mg twice daily on days 19 to 26 of the two subsequent cycles (Egyptian National Drug Formulary) to prevent recurrence - repeated here so a physician managing heavy bleeding without (or before) a fibroid diagnosis - including adenomyosis or no identified cause - reaches the same guidance without needing to search a fibroid- specific entry. Kept at line 2, as in uterine-fibroids, since NG88 positions oral progestogen as an alternative once the LNG-IUS has been declined or is unsuitable. Caution The two sources disagree four-fold on the acute dose: StatPearls gives 20 mg three times daily for 7 days, the Egyptian formulary 5 mg three times daily for 10 days. The international figure leads here per the app's source policy; both are printed. Evaluate abnormal bleeding that persists or is severe before repeating courses. Contraindicated in pregnancy, in current or past deep vein thrombosis or pulmonary embolism, in hepatic impairment or disease, and in undiagnosed abnormal genital bleeding. Never with tranexamic acid. The Egyptian formulary's norethisterone monograph lists that combination under Risk X - avoid, not merely monitor - and both drugs are offered in this entry. This cyclical regimen is not reliably contraceptive even though it is a progestogen; advise separate contraception if needed. Side effects include fluid retention, bloating, weight gain, mood changes, and breast tenderness. Refer to gynaecology if bleeding has not improved after 3 cycles, or if intermenstrual/postcoital/postmenopausal bleeding or a pelvic mass is present. The formulary's regimen for heavy or dysfunctional bleeding is 5 mg three times daily for 10 days, with bleeding usually stopping inside 48 hours; it also lists 5 mg twice daily on days 19 to 26. Egypt CIDOLUT NOR 5 MG 20 TABS. CID 36.00 EGP (1.80/unit) CIDOLUT NOR 5 MG 30 TABS. CID 57.00 EGP (1.90/unit) STERONATE 5 MG 20 TABS. HI-PHARM 56.00 EGP (2.80/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)