From the Guidelines
Menorrhagia should be treated with NSAIDs, hormonal treatment, or antifibrinolytic agents, depending on the patient's preferences, treatment goals, and medical history, as recommended by the most recent guidelines 1.
Treatment Options
The treatment of menorrhagia depends on the underlying cause and severity of the condition. According to the latest guidelines, the following treatment options can be considered:
- NSAIDs, such as ibuprofen, for short-term treatment (5-7 days) to reduce blood loss by 20-40% by decreasing prostaglandin production
- Hormonal treatment, such as combined oral contraceptives or low-dose estrogen, for short-term treatment (10-20 days) to reduce bleeding by 40-50%
- Antifibrinolytic agents, such as tranexamic acid, for short-term treatment (5 days) to reduce bleeding by about 40-60%
Underlying Conditions
It is essential to consider underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids), and treat or refer for care if necessary 1.
Surgical Interventions
For women with underlying conditions like fibroids or polyps, surgical interventions such as endometrial ablation, myomectomy, or hysterectomy may be necessary if medical treatment fails, is contraindicated, or is not tolerated 1.
Iron Supplementation
Iron supplementation, such as ferrous sulfate 325 mg daily, is crucial to prevent or treat anemia resulting from blood loss 1.
Patient Education
Patients should be educated to seek medical attention if they experience heavy or prolonged bleeding, soak through pads or tampons hourly, pass large clots, or experience symptoms of anemia like fatigue or dizziness 1.
From the FDA Drug Label
Abnormal Uterine Bleeding Due to Hormonal Imbalance in the Absence of Organic Pathology Beginning on the calculated 16th or 21st day of the menstrual cycle, 5 or 10 mg of medroxyprogesterone acetate may be given daily for 5 to 10 days Patients with a past history of recurrent episodes of abnormal uterine bleeding may benefit from planned menstrual cycling with medroxyprogesterone acetate.
Menorrhagia is a type of abnormal uterine bleeding. The drug label suggests that medroxyprogesterone acetate may be used to treat abnormal uterine bleeding due to hormonal imbalance.
- The recommended dosage is 5 or 10 mg daily for 5 to 10 days, starting on the calculated 16th or 21st day of the menstrual cycle.
- Patients with a history of recurrent episodes of abnormal uterine bleeding may benefit from planned menstrual cycling with medroxyprogesterone acetate 2.
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 3.
- Approximately 30% of women complain of menorrhagia, and it is estimated that about 5% of women of reproductive age will seek help for menorrhagia annually 4, 3.
- The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years 5.
Etiology and Investigation 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 3.
- A pelvic examination and vaginal sonography should be carried out as the most important supplemental examination, and hysteroscopy or hysterosonography can be suggested as a second-line procedure 4, 5.
- MRI is not recommended as a first-line procedure, and a blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it 5.
Medical and Surgical Management of Menorrhagia
- Effective medical treatments suitable for long-term use include intrauterine progestogens, antifibrinolytic agents (tranexamic acid), and nonsteroidal anti-inflammatory agents (mefenamic acid) 3.
- The combined oral contraceptive pill (OCP) is claimed to have a variety of beneficial effects, but the evidence from one study is not sufficient to adequately assess its effectiveness 6.
- Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB, and if this fails, a conservative surgical technique must be proposed 5.
- Hysterectomy is not recommended as a first-line treatment, but it may be considered for women who do not wish to become pregnant in the future and who have idiopathic AUB 5.
Treatment Options and Outcomes
- 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 4.
- Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate, and treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive 4.
- With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment, and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care 4.