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

From the Guidelines

Hormone Replacement Therapy (HRT) is generally not recommended for managing menorrhagia in women with a history of spontaneous coronary artery dissection (SCAD) due to the potential risks associated with exogenous hormones. In the context of SCAD, the use of HRT for heavy menstrual bleeding is relatively contraindicated, and careful clinical judgment is required 1.

Alternative Management Options

Instead, other medical therapies for heavy menstrual bleeding can be considered, such as:

• Progestin-eluting intrauterine devices, like the levonorgestrel 20 μg/d–releasing device, which can reduce menstrual blood loss by 71% to 95% 1
• Cyclic oral progestin treatment, which can reduce bleeding by 87% 1
• High-dose oral or injectable progestin-only medications for short-term use in hemodynamically unstable women 1

Considerations for SCAD Patients

For patients with SCAD, it is essential to avoid both pregnancy and exogenous hormones, making conservative surgical treatment for heavy menstrual bleeding, such as second-generation endometrial ablation techniques, a potential option 1. These interventions can effectively manage bleeding, reduce pregnancy risk, and be performed on patients without significant risks.

Key Takeaways

• HRT is not typically recommended for managing menorrhagia in women with SCAD
• Alternative medical therapies, such as progestin-eluting intrauterine devices and cyclic oral progestin treatment, can be effective in reducing heavy menstrual bleeding
• Conservative surgical treatment options may be considered for patients with SCAD who experience heavy menstrual bleeding 1

From the Research

Role of Hormone Replacement Therapy (HRT) in Managing Menorrhagia

• Hormone replacement therapy (HRT) is used to manage menorrhagia (heavy menstrual flow) in women, particularly those with abnormal uterine bleeding (AUB) related to endometrial causes, ovulatory dysfunction, and coagulopathy 2.
• HRT, including combined hormonal contraceptives, progestin-only preparations, and intrauterine release of levonorgestrel, is endorsed as the first-line treatment for heavy menstrual bleeding (HMB) in several international guidelines 2.
• The levonorgestrel-releasing intrauterine system (LNG IUS) is a effective treatment for HMB, reducing menstrual blood loss by up to 90% and improving quality of life 3, 4.
• Progesterone or progestogen-releasing intrauterine systems are more effective than oral medication in reducing HMB, but may be associated with more minor adverse effects, such as pelvic pain and breast tenderness 3, 4.
• HRT, particularly progestogens, can help regulate intermenstrual bleeding and decrease HMB in women of reproductive age or those who are perimenopausal 5.
• In menopausal women, progesterones and progestogens can prevent endometrial hyperplasia and reduce the development of endometrial cancer 6, 5.

Comparison of HRT with Other Treatments

• The LNG IUS is more effective than oral cyclical norethisterone in reducing HMB, but may be associated with more side effects 4.
• The LNG IUS is less effective than hysterectomy in reducing HMB, but is more cost-effective and improves quality of life 3, 4.
• The LNG IUS is comparable to endometrial ablation in terms of satisfaction and quality of life, but may be associated with more minor adverse effects 3, 4.

Benefits and Risks of HRT

• HRT can reduce the risk of endometrial hyperplasia and cancer, particularly in menopausal women 6, 5.
• HRT can improve quality of life and reduce the incidence of HMB in women of reproductive age or those who are perimenopausal 2, 3, 4, 5.
• HRT may be associated with minor adverse effects, such as pelvic pain, breast tenderness, and intermenstrual bleeding 3, 4.