Phase-Based Management of Heavy Menstrual Bleeding in Women with Bleeding Disorders: From Acute Control to Long-Term Maintenance.

Heavy menstrual bleeding (HMB) is a common and clinically challenging manifestation in women with inherited or acquired bleeding disorders (BDs), often leading to iron-deficiency anemia, recurrent emergency visits, transfusion requirements, and impaired quality of life. Although current management strategies commonly distinguish acute from long-term treatment, this binary approach may not adequately address the vulnerable interval after initial bleeding control, during which recurrent bleeding remains common and definitive maintenance therapy may not yet be feasible. In this narrative review, we propose a phase-based framework for the management of HMB in women with BDs, organized into acute bleeding control, bridging stabilization, and long-term maintenance. Acute management should be guided by hemodynamic status and may include resuscitation, correction of anemia and hemostatic defects, high-dose combined hormonal therapy or high-dose progestins, antifibrinolytic therapy, and selected mechanical interventions. Bridging stabilization aims to maintain endometrial quiescence, prevent early recurrence, allow hematologic recovery, and create a safer window for transition to definitive long-term therapy. Potential bridging options include progestin-based regimens, continuous combined hormonal regimens in appropriate patients, depot progestins, antifibrinolytic therapy during bleeding episodes, and selected use of low-dose mifepristone. Long-term maintenance should be individualized according to the underlying bleeding disorder, thrombotic risk, anticoagulant use, fertility goals, treatment acceptability, and patient preference. The levonorgestrel-releasing intrauterine system should be regarded primarily as a definitive long-term maintenance option rather than a conventional bridging therapy, and its insertion may be delayed until bleeding is controlled and hematologic conditions permit safe placement. This phase-based approach may provide a practical framework for multidisciplinary care, but prospective studies are needed to compare bridging strategies, define optimal transition pathways, and evaluate standardized outcomes in this high-risk population.