From the Guidelines
Menorrhagia should be managed with a treatment approach that prioritizes the patient's goals and medical history, considering options such as NSAIDs, hormonal treatment, or alternative contraceptive methods, as recommended by the most recent guidelines 1.
Treatment Options
The management of menorrhagia involves exploring patient goals, including continued method use or method discontinuation, and providing reassurance and advice on bleeding irregularities or other side effects.
- If the patient wants to continue use, provide reassurance and advise the patient that they may contact their provider at any time to discuss bleeding irregularities or other side effects.
- If the patient desires removal or discontinuation of the method at any time, remove the method (if IUD or implant), offer counseling on alternative contraceptive methods, and initiate another method if desired.
Medical Treatment
Medical treatments for menorrhagia include:
- NSAIDs, such as ibuprofen, for short-term treatment (5-7 days) to reduce blood loss by 20-40% 1.
- Hormonal treatment, such as low-dose combined oral contraceptives or estrogen, for short-term treatment (10-20 days) to regulate cycles and reduce bleeding 1.
- Antifibrinolytic agents, such as tranexamic acid, for short-term treatment (5 days) to reduce bleeding 1.
Surgical Options
Surgical options, such as endometrial ablation or hysterectomy, may be considered for severe cases unresponsive to medical management, or if the patient has concomitant significant intracavitary lesions 1.
Underlying Cause
The underlying cause of menorrhagia should be investigated, as it may result from conditions like uterine fibroids, polyps, adenomyosis, or bleeding disorders, and treated or referred for care if necessary 1.
Iron Supplementation
Iron supplementation, such as ferrous sulfate 325mg daily, may be necessary to prevent or treat anemia resulting from chronic heavy bleeding 1.
From the Research
Definition and Prevalence of Menorrhagia
- Menorrhagia is defined as a complaint of heavy cyclical menstrual bleeding occurring over several consecutive cycles, with a total menstrual blood loss equal to or greater than 80 ml per menstruation 2.
- It is estimated that approximately 30% of women complain of menorrhagia, and about 5% of women of reproductive age will seek help for menorrhagia annually 3, 2.
- Menorrhagia affects the lives of many women, interfering with their quality of life, and is a common condition in women of reproductive age, affecting 2 to 5 of every 10 women 4, 5.
Causes and Diagnosis of Menorrhagia
- In approximately 50% of cases of menorrhagia, no pathology is found at hysterectomy, and abnormal levels of prostaglandins or the fibrinolytic system in the endometrium have been implicated 2.
- Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age) 3.
- Diagnosis of menorrhagia involves a pelvic examination, and if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination 3.
Treatment Options for Menorrhagia
- Effective medical treatments suitable for long-term use include intrauterine progestogens, antifibrinolytic agents (tranexamic acid), and nonsteroidal anti-inflammatory agents (mefenamic acid) 2, 4.
- The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective treatment for reducing menstrual blood loss, and is considered the first-line medical therapy for heavy menstrual bleeding (HMB) 6, 5.
- Surgical interventions, such as hysterectomy and endometrial ablation, are reserved for women with significant pelvic pathology and those unresponsive to medical therapy 6, 5.
- Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy 3.
Ranking of Treatments for Menorrhagia
- Evidence suggests LNG-IUS is the best first-line treatment for reducing menstrual blood loss (MBL); antifibrinolytics are probably the second best, and long-cycle progestogens are likely the third best 5.
- For second-line treatments, evidence suggests hysterectomy is the best treatment for reducing bleeding, followed by REA and NREA 5.