What are the options for pain control in menorrhagia (heavy menstrual bleeding)?

From the Guidelines

Pain control for menorrhagia should primarily involve nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) taken during menstruation, as recommended by the most recent guidelines 1. The management of menorrhagia involves a step-wise approach, starting with the least invasive methods.

• NSAIDs are the first line of treatment for pain control, as they not only reduce pain but also decrease menstrual blood flow by 20-40% by inhibiting prostaglandin production, which contributes to both pain and excessive bleeding.
• For optimal effect, start NSAIDs 1-2 days before expected menstruation and continue throughout the heaviest bleeding days.
• If NSAIDs provide insufficient relief, hormonal treatments like combined oral contraceptives, tranexamic acid (1000-1300mg three times daily during heavy bleeding days), or a levonorgestrel intrauterine system can simultaneously reduce bleeding and associated pain, as suggested by 1 and 1. Some key points to consider when managing menorrhagia include:
• Exploring patient goals, including continued method use or method discontinuation, as outlined in 1.
• Considering underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, as recommended in 1.
• Providing reassurance and advising the patient that they may contact their provider at any time to discuss bleeding irregularities or other side effects, as suggested in 1. It's essential to note that the most recent guidelines 1 provide the most up-to-date recommendations for managing menorrhagia, and these should be prioritized when making treatment decisions.

From the FDA Drug Label

In patients with primary dysmenorrhea, ibuprofen tablets have been shown to reduce elevated levels of prostaglandin activity in the menstrual fluid and to reduce resting and active intrauterine pressure, as well as the frequency of uterine contractions. Dysmenorrhea: For the treatment of dysmenorrhea, beginning with the earliest onset of such pain, ibuprofen tablets should be given in a dose of 400 mg every 4 hours as necessary for the relief of pain.

Pain Control for Menorrhagia:

• The FDA drug label for ibuprofen tablets does provide information on the treatment of dysmenorrhea, which is related to menorrhagia.
• Ibuprofen may be used to control pain associated with menorrhagia, although the label specifically discusses dysmenorrhea.
• The recommended dose for dysmenorrhea is 400 mg every 4 hours as necessary.
• There is no direct information on the treatment of menorrhagia, but ibuprofen's mechanism of action and its use in treating dysmenorrhea suggest it may be beneficial in controlling pain associated with menorrhagia 2 2.

From the Research

Pain Control for Menorrhagia

• Menorrhagia is a common disorder characterized by heavy menstrual bleeding, and various treatments are available to manage the condition, including non-steroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5.
• NSAIDs have been shown to reduce menstrual blood loss by 30% to 50% and are also effective in relieving dysmenorrhea, a common symptom associated with menorrhagia 3, 6.
• The effectiveness of NSAIDs in reducing menstrual blood loss is lower compared to other treatments such as tranexamic acid, danazol, or the levonorgestrel-releasing intrauterine system (LNG IUS) 4, 5.
• However, NSAIDs are generally better tolerated than danazol, which is associated with more adverse events 4, 5.

Treatment Options for Menorrhagia

• Various treatment options are available for menorrhagia, including:
  • NSAIDs: effective in reducing menstrual blood loss and relieving dysmenorrhea 3, 6, 4, 5.
  • Tranexamic acid: reduces menstrual blood loss by approximately 50% 3.
  • Danazol: effective in reducing menstrual blood loss, but associated with more adverse events 4, 5.
  • LNG IUS: reduces menstrual blood loss by 65% to 85% 3.
  • Oral contraceptives: may be useful in stopping acute bleeding and reducing menstrual flow by approximately 50% 3.

Prevention of Heavy Menstrual Bleeding and Pain

• Various interventions are available to prevent heavy menstrual bleeding and pain associated with intrauterine device (IUD) use, including:
  • NSAIDs: may be effective in preventing heavy menstrual bleeding and pain 7.
  • Tolfenamic acid: may prevent heavy bleeding compared to placebo 7.
  • Vitamin B1: may reduce menstrual blood loss and duration of bleeding 7.
  • Ulipristal acetate: may not reduce the number of bleeding days in women using the LNG IUD 7.