What is the treatment for uterine bleeding (metrorrhagia)?

From the Guidelines

To treat uterine bleeding, first identify the cause and severity, and consider medical management with tranexamic acid, NSAIDs, or hormonal treatments, such as combined hormonal contraceptives or progestin-only options, as recommended by the most recent study 1. For acute heavy bleeding, seek immediate medical attention. The following treatment options can be considered:

• Tranexamic acid (1000-1300mg three times daily during heavy bleeding) to reduce blood loss by up to 50% 1
• NSAIDs like ibuprofen (600mg every 6 hours during bleeding) to decrease flow by 20-40% and help with pain 1
• Hormonal management with combined hormonal contraceptives (containing estrogen and progestin) which can reduce bleeding by 40-50%, or progestin-only options like oral norethindrone acetate (5-10mg daily), medroxyprogesterone acetate (10mg daily for 10-14 days), or levonorgestrel IUD insertion 1 For persistent bleeding, endometrial ablation or hysterectomy may be considered. Underlying conditions like fibroids, polyps, or endometriosis may require specific treatments, such as selective progesterone receptor modulators (SPRMs) 1. Iron supplementation (325mg ferrous sulfate 1-3 times daily) is important to prevent or treat anemia. These treatments work by stabilizing the endometrial lining, reducing inflammation, inhibiting fibrinolysis, or addressing hormonal imbalances that contribute to abnormal bleeding patterns. It is essential to consider the patient's individual needs and medical history when selecting a treatment option, as recommended by 1. In cases where medical management is not effective, surgical options may be necessary, and the patient should be counseled on alternative methods, as suggested by 1.

From the FDA Drug Label

Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. Secondary amenorrhea, abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 2. 5 to 10 mg norethindrone acetate tablets may be given daily for 5 to 10 days to produce secretory transformation of an endometrium that has been adequately primed with either endogenous or exogenous estrogen. Norethindrone Acetate Tablets, USP are indicated for the treatment of secondary amenorrhea, endometriosis, and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer.

Treatment for uterine bleed due to hormonal imbalance:

• 2.5 to 10 mg of norethindrone acetate tablets may be given daily for 5 to 10 days 2
• This treatment is indicated for abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 2
• Key considerations: the patient's condition should be due to hormonal imbalance and not organic pathology, and the treatment should be adapted to the individual patient's response.

From the Research

Treatment Options for Uterine Bleed

• Medical management is the first-line approach for treating abnormal uterine bleeding, with options including parenteral estrogen, combined oral contraceptives, progestin-only regimens, and tranexamic acid 3
• Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid 3
• Nonsteroidal anti-inflammatory drugs may be used in combination with hormonal methods and tranexamic acid to decrease menstrual bleeding 3, 4, 5
• Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions 3, 4

Surgical Interventions

• Surgical therapy may be considered for patients who no longer desire future fertility and have associated pelvic pathologic disorders, or for those who fail all medical regimens 4, 6
• Options for surgical intervention include hysterectomy or endometrial ablation 4, 5

Specific Patient Populations

• Women with inherited bleeding disorders, such as von Willebrand's disease, can be treated with hormonal methods and tranexamic acid 3, 4
• Women on anticoagulation therapy should consider using progestin-only methods and a gonadotropin-releasing hormone agonist to treat heavy menstrual bleeding 3
• Patients with levonorgestrel intrauterine devices can be treated with nonsteroidal anti-inflammatory drugs or estradiol for abnormal uterine bleeding 7

Treatment Approach

• The treatment approach should be individualized based on the patient's medical history, risk factors, and diagnosis 3
• The main objective of treatment is to reduce menstrual flow and morbidity, and improve quality of life 6
• Treatment may be surgical or pharmacological, with pharmacological treatment based mainly on hormonal therapy, anti-inflammatory drugs, and antifibrinolytics 6