What is the role of Hormone Replacement Therapy (HRT) in managing menorrhagia (heavy menstrual flow)?

From the Guidelines

Hormone Replacement Therapy (HRT) is not the first-line approach for managing menorrhagia in women with spontaneous coronary artery dissection (SCAD), and its use requires careful clinical judgment due to the potential risks associated with exogenous hormones. When considering the management of heavy menstrual bleeding, it is essential to prioritize the patient's cardiovascular health and avoid therapies that may increase the risk of further cardiovascular events. According to the American Heart Association statement 1, medical management with HRT is relatively contraindicated in SCAD, and alternative nonhormonal options should be considered.

Some key points to consider when managing menorrhagia in women with SCAD include:

• Reassessing the indication for ongoing antiplatelet therapy and discontinuing its use if appropriate 1
• Avoiding nonsteroidal anti-inflammatory drugs and tranexamic acid due to their association with myocardial infarction and thrombosis 1
• Considering progestin-eluting intrauterine devices, such as the levonorgestrel 20 μg/d–releasing device, which can reduce menstrual blood loss by 71% to 95% 1
• Using cyclic oral progestin treatment, which can reduce bleeding by 87% and result in irregular bleeding and often reduction of menses to only light bleeding 1
• Evaluating the patient's overall health and considering alternative treatments, such as second-generation endometrial ablation techniques, which may be more effective in managing bleeding and reducing pregnancy risk 1

In general, the management of menorrhagia in women with SCAD requires a careful and individualized approach, taking into account the patient's cardiovascular health and the potential risks and benefits of different therapies. The primary goal is to prioritize the patient's morbidity, mortality, and quality of life, and to select the most appropriate treatment option based on the latest evidence and clinical guidelines.

From the Research

Role of Hormone Replacement Therapy (HRT) in Managing Menorrhagia

• HRT is not directly mentioned as a treatment for menorrhagia in the provided studies, but the use of progestogens and estrogen in HRT regimens is discussed in the context of managing menstrual bleeding and endometrial hyperplasia 2, 3.
• Low-dose HRT regimens, including continuous combined estrogen and progestogen therapy, have been shown to reduce menstrual bleeding and protect the endometrium from hyperplasia 2.
• The addition of progestogens to estrogen therapy reduces the risk of endometrial hyperplasia and improves adherence to therapy, but may cause irregular bleeding and spotting 3.

Alternative Treatments for Menorrhagia

• The levonorgestrel-releasing intrauterine system (LNG-IUS) is a effective treatment for heavy menstrual bleeding, with a greater reduction in bleeding and improvement in quality of life compared to oral medical therapy 4, 5.
• The LNG-IUS is also more effective than oral medication in reducing menstrual blood loss and improving quality of life, but is associated with more minor adverse effects 5.
• Other treatments, such as endometrial ablation and hysterectomy, may also be effective in reducing menstrual bleeding, but the evidence is inconsistent and of low quality 4, 5.

Progestogen Therapy for Menorrhagia

• Cyclical progestogen therapy, including short-cycle and long-cycle regimens, has been shown to reduce menstrual blood loss, but the evidence is limited by low or very low gradings of quality 6.
• Long-cycle progestogen therapy may be similar to the combined vaginal ring in reducing menstrual blood loss, but is inferior to the LNG-IUS and tranexamic acid 6.
• Progestogen-releasing intrauterine systems, such as the LNG-IUS, are effective in reducing menstrual bleeding and improving quality of life, but may be associated with minor adverse effects 5.