What are the treatment options for heavy menstrual bleeding?

From the Guidelines

The most effective treatment for heavy menstrual bleeding is the levonorgestrel 20 μg/d–releasing intrauterine device, which can reduce menstrual blood loss by 71% to 95%. This treatment option is particularly useful for controlling bleeding and protecting against pregnancy, with minimal increase in systemic progesterone levels 1. Other medical therapies, such as cyclic oral progestin treatment, can also reduce bleeding by 87%, but may result in irregular bleeding and light menses 1.

Medical Treatment Options

• Progestin-eluting intrauterine devices, such as the levonorgestrel 20 μg/d–releasing device, are effective in controlling bleeding and protecting against pregnancy 1
• Cyclic oral progestin treatment can reduce bleeding by 87%, but may result in irregular bleeding and light menses 1
• High-dose oral or injectable progestin-only medications may be considered for short-term use in hemodynamically unstable women 1

Surgical Treatment Options

• Second-generation endometrial ablation techniques, such as thermal balloon, microwave, or radiofrequency, may be considered for long-term management of heavy menstrual bleeding 1
• These ablative procedures can effectively manage bleeding, reduce pregnancy risk, and can be performed on patients without significant morbidity 1

It is essential to note that patients with spontaneous coronary artery dissection (SCAD) may require careful clinical judgment when managing heavy menstrual bleeding, as certain treatments, such as nonsteroidal anti-inflammatory drugs and tranexamic acid, may be contraindicated due to their association with myocardial infarction and thrombosis 1.

From the Research

Treatment Options for Heavy Menstrual Bleeding

The treatment options for heavy menstrual bleeding (HMB) can be categorized into medical and surgical interventions.

• Medical management is usually the first line of treatment and can be effective in reducing menstrual blood loss, as seen in studies 2, 3, 4.
• The effectiveness of treatments to reduce HMB due to endometrial dysfunction in descending order is as follows:
  • The levonorgestrel-releasing intrauterine system (LNG-IUS)
  • Combined hormonal contraceptives (oral or transvaginal)
  • Tranexamic acid
  • Long-course oral progestogens (≥3 weeks per cycle) 2
• Nonsteroidal anti-inflammatory drugs (NSAIDs) and short-course oral progestogens (≤14 days per cycle) may also be effective in reducing menstrual blood loss, although the reduction may be less impressive 2, 4, 5, 6
• For women not seeking pregnancy, the LNG-IUS is the first-line medical therapy for HMB, with combined hormonal contraceptives as second choice 2

Medical Management

Medical management of HMB usually provides effective control of the condition, irrespective of the underlying cause.

• The aim of medical management is to reduce menstrual blood loss and improve the quality of life of women with HMB, as discussed in studies 2, 3, 4.
• Medical treatments available for HMB include:
  • Antifibrinolytics
  • Nonsteroidal anti-inflammatory preparations
  • Oral contraceptive pills
  • Oral, injectable, and intrauterine progestogens
  • Selective progesterone receptor modulators 3

Surgical Interventions

Surgical interventions should be reserved for women with significant pelvic pathology and those unresponsive to medical therapy.

• Surgical options may include endometrial ablation or hysterectomy, which can be effective in reducing menstrual blood loss, as seen in study 4
• However, surgical interventions should only be considered after medical management has been tried and failed, as they are associated with more risks and complications.