From the Guidelines
Management of menorrhagia should prioritize medical treatment, with tranexamic acid and hormonal medications such as combined oral contraceptives being first-line options, and surgical approaches like endometrial ablation or hysterectomy considered only when medical management fails or is contraindicated. The most recent and highest quality study, 1, published in 2024, supports the use of endometrial ablation as a minimally invasive technique for patients with uterine fibroids associated with heavy menstrual bleeding who are refractory or intolerant to medical therapy. However, this approach is only indicated in patients who do not desire future pregnancy due to the associated risks of extrauterine pregnancy, preterm delivery, and stillbirth.
When considering medical treatment, the following options are available:
- Combined oral contraceptives to reduce menstrual blood loss by thinning the endometrium and regulating cycles
- Tranexamic acid (1000-1500mg three times daily during heavy bleeding days) to reduce bleeding by inhibiting fibrinolysis
- Nonsteroidal anti-inflammatory drugs like mefenamic acid (500mg three times daily during menses) to reduce blood loss by 20-40% by decreasing prostaglandin production
- The levonorgestrel intrauterine system (Mirena) for longer-term management, providing excellent control by causing endometrial atrophy and reducing bleeding by up to 90% after several months
It is essential to investigate underlying causes such as fibroids, polyps, adenomyosis, or coagulation disorders through history, examination, blood tests, and imaging before initiating treatment. Iron supplementation (ferrous sulfate 325mg daily) is often necessary to treat or prevent anemia resulting from heavy blood loss. Management should be tailored to the patient's age, desire for fertility, and underlying pathology, as outlined in the 2014 guidelines by the American College of Obstetricians and Gynecologists 1.
From the Research
Management of Menorrhagia
- Menorrhagia is a common gynaecological complaint characterized by heavy menstrual bleeding, defined as menstrual blood loss in excess of 80 ml per cycle 2.
- 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 3.
- Several drugs have been demonstrated to decrease menstrual bleeding in patients with menorrhagia, including:
- Non-steroidal anti-inflammatory drugs, which decrease bleeding by 30% to 50% 4 or 20-60% 5.
- Oral contraceptives, which may be useful to stop acute bleeding and decrease menstrual flow by approximately 50% 4.
- Tranexamic acid, a plasminogen inhibitor, which decreases flow by approximately 50% 4 or 20-60% 5.
- Levonorgestrel-releasing intrauterine system (LNG-IUS), which reduces menstrual blood loss by 65% to 85% 4 or is the most effective treatment for heavy menstrual bleeding due to endometrial dysfunction 6.
Diagnosis and Treatment
- Diagnosis of menorrhagia involves a pelvic examination, vaginal sonography, and endometrial biopsy to rule out any uterine abnormalities or cervical disease 5, 3.
- Treatment options for menorrhagia include medical management, such as hormone therapy or non-steroidal anti-inflammatory drugs, and surgical interventions, such as endometrial ablation or hysterectomy 4, 5, 3, 6.
- The choice of treatment depends on the underlying cause of menorrhagia, patient preferences, and medical history 5, 2.
- Medical management is usually the first line of treatment, with surgical interventions reserved for women with significant pelvic pathology or those unresponsive to medical therapy 6.
Treatment Efficacy
- The effectiveness of treatments for heavy menstrual bleeding due to endometrial dysfunction in descending order is:
- The reduction in menstrual blood loss achieved with nonsteroidal anti-inflammatory drugs and short-course oral progestogens (≤14 days per cycle) is less impressive but may be sufficient for women who have marginally increased blood loss 6.