From the Guidelines
Treatment for menorrhagia should start with first-line medical management, including NSAIDs and estrogen-progestin oral contraceptive pills, which reduce bleeding symptoms. According to the most recent study 1, first-line medical management is the preferred initial approach for managing menorrhagia, especially for patients with pedunculated submucosal uterine fibroids associated with heavy bleeding.
Medical Management Options
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can reduce blood loss by 20-40%
- Hormonal options include combined oral contraceptives, which regulate cycles and reduce bleeding
- The levonorgestrel intrauterine system (Mirena) can reduce bleeding by up to 90% over 3-6 months
- Oral progestins like medroxyprogesterone acetate (10mg daily for 10-14 days per cycle)
- Tranexamic acid (1000-1300mg three times daily during menstruation) reduces bleeding by inhibiting fibrinolysis
Additional Considerations
- For women with underlying bleeding disorders, desmopressin or clotting factor replacement may be necessary
- Iron supplementation (325mg ferrous sulfate 1-3 times daily) is often needed alongside other treatments to address anemia resulting from blood loss
- If medical management fails or isn't appropriate, surgical options include endometrial ablation or hysterectomy for definitive treatment
- The choice of treatment depends on the underlying cause of menorrhagia, the woman's age, desire for future fertility, and other medical conditions, as noted in 1, 1, 1, and 1.
Second-Line Medical Management
Second-line medical management includes parenteral GnRH agonists and oral GnRH antagonists, which can reduce bleeding symptoms and tumor volume, but are associated with hypoestrogenic effects, as discussed in 1. Combination treatment with low doses of estrogen and progestin can mitigate these symptoms. Progesterone receptor modulators like ulipristal acetate are also effective in reducing bleeding and bulk symptoms, but their use is limited by reports of hepatotoxicity.
From the Research
Treatment Options for Menorrhagia
The treatment options for menorrhagia (heavy menstrual bleeding) can be categorized into medical and surgical interventions.
- Medical treatments:
- Non-steroidal anti-inflammatory drugs (NSAIDs) and tranexamic acid can reduce menstrual blood loss by 20-60% 2
- Hormonal intrauterine system (IUS) is effective in reducing menstrual blood loss, comparable to endometrial ablation or hysterectomy 2
- Oral contraceptive pills can reduce menstrual blood loss by approximately 50% 3
- Levonorgestrel intra-uterine device can reduce menstrual blood loss by 65% to 85% 3
- Surgical treatments:
- Endometrial ablation is a minimally invasive surgical procedure that can treat menorrhagia in select patients 3
- Hysterectomy is the most efficient treatment for menorrhagia due to interstitial myomas and may be proposed as a second or third line of treatment 4
- Hysteroscopic polypectomy can treat menorrhagia associated with endometrial polyps, and hysteroscopic myomectomy can manage menorrhagia related to submucosal myomas 4
Factors Influencing Treatment Choice
The choice of treatment for menorrhagia depends on various factors, including:
- Desire for contraception: Oral combination contraceptives and continuously dosed progestogens are the first choice drugs for essential menorrhagia if contraception is desired 5
- Underlying cause of menorrhagia: Treatment options vary depending on the underlying cause, such as fibroids, endometrial polyps, or bleeding disorders 4, 5
- Patient's preferences and medical history: The treatment choice should take into account the patient's preferences, medical history, and potential side effects of the treatment options 2, 5
Diagnosis and Assessment
A rigorous assessment of the patient is essential to provide the best treatment options for menorrhagia. This includes: