What are the causes and treatments of Menorrhagia (abnormally heavy or prolonged menstrual bleeding)?

From the Guidelines

Menorrhagia should be managed with a treatment approach that prioritizes the patient's goals, medical history, and preferences, with first-line options including NSAIDs, hormonal treatments, or antifibrinolytic agents, as recommended by the most recent guidelines 1.

Treatment Options

The management of menorrhagia involves a step-wise approach, starting with the identification and treatment of any underlying causes, such as structural abnormalities (fibroids, polyps), hormonal imbalances, bleeding disorders, or medications.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (600-800mg three times daily during menses) can reduce blood loss by 20-40% 1.
• Hormonal options include combined oral contraceptives, which can reduce bleeding by 40-50%, or the levonorgestrel intrauterine system (Mirena), which reduces bleeding by up to 90% 1.
• Tranexamic acid (1000mg three times daily during menses) is an antifibrinolytic that can reduce bleeding by 40-60% 1.

Considerations

The choice of treatment should be individualized based on the woman's age, desire for future fertility, underlying causes, and preferences.

• If the patient wants to continue using their current contraceptive method, provide reassurance and advise the patient that they may contact their provider at any time to discuss bleeding irregularities or other side effects 1.
• 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 1.

Underlying Causes

Identifying and addressing the underlying cause of menorrhagia is essential for effective management.

• Consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids) 1.
• If an underlying health condition is found, treat the condition or refer for care 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.
• The prevalence of abnormal uterine bleeding (AUB), which includes menorrhagia, is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years 3.
• Approximately 30% of women complain of menorrhagia, and it is estimated that one-third of all women experience heavy menstrual bleeding at some point in their life 4, 2.

Causes and Risk Factors of Menorrhagia

• Menorrhagia can be caused by various factors, including thyroid dysfunction, coagulation defects (most commonly von Willebrand disease), endometrial polyps, and submucosal fibroids 5.
• Other risk factors for menorrhagia include polycystic ovary syndrome, uncontrolled diabetes mellitus, hyperprolactinemia, and use of antipsychotics or antiepileptics 5.
• 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.

Diagnosis and Evaluation of Menorrhagia

• The diagnosis of menorrhagia is based on a patient's medical history, physical examination, and laboratory tests, including a blood count for red cells and platelets to test for anemia 3.
• Pelvic ultrasound, both abdominal and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB, while hysteroscopy or hysterosonography can be suggested as a second-line procedure 3.
• Transvaginal ultrasonography or saline infusion sonohysterography may be used to evaluate menorrhagia, especially in cases where structural causes are suspected 5.

Treatment Options for Menorrhagia

• Medical treatment options for menorrhagia include the levonorgestrel-releasing intrauterine system (LNG-IUS), combined hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs (NSAIDs) 5, 4, 3, 6.
• The LNG-IUS is considered the most effective medical treatment for menorrhagia, reducing menstrual blood loss by up to 90% 6.
• Surgical interventions, such as polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation, may be considered in cases where medical management is ineffective or when clear structural causes are identified 5, 4, 3.