What are the causes and treatments of menorrhagia (heavy menstrual bleeding)?

From the Guidelines

Heavy menstrual bleeding, also called menorrhagia, can be managed through several approaches, with the most effective treatment being the levonorgestrel intrauterine system (Mirena), which reduces bleeding by 80-90% within 3-6 months 1.

Causes of Menorrhagia

The causes of menorrhagia can be structural, such as polyps, adenomyosis, leiomyoma, and malignancy, or nonstructural, including coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified causes, as described by the PALM-COEIN classification system 1.

Treatment Options

For immediate treatment, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (600-800mg every 6-8 hours during bleeding) can reduce flow by 20-40% and help with pain. Hormonal options include combined oral contraceptives taken cyclically or continuously, which reduce bleeding by thinning the uterine lining. Tranexamic acid (1000mg three times daily during bleeding) works by preventing blood clot breakdown and can reduce flow by 40-60% 1.

Investigation and Referral

The underlying cause of heavy bleeding should be investigated, as it could result from conditions like fibroids, polyps, adenomyosis, or hormonal imbalances. Patients should seek medical attention if they soak through pads/tampons hourly, pass large clots, experience bleeding lasting over 7 days, or develop anemia symptoms like fatigue and dizziness.

Surgical Options

For women not responding to medical treatments, endometrial ablation or hysterectomy may be considered, especially if there are concomitant significant intracavitary lesions 1. Some key points to consider:

• The levonorgestrel intrauterine system (Mirena) is a highly effective treatment for menorrhagia, reducing bleeding by 80-90% within 3-6 months 1.
• Tranexamic acid is a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids 1.
• GnRH agonists and antagonists can be used for short-term treatment to reduce bleeding symptoms and tumor volume, but have hypoestrogenic effects and are typically used for temporary situations 1.
• Progesterone receptor modulators, such as ulipristal acetate, may reduce both bleeding and bulk symptoms, but have reports of hepatotoxicity and are not approved for use in the United States 1.

From the Research

Causes of Menorrhagia

• Menorrhagia can be caused by various factors, including thyroid dysfunction, coagulation defects (most commonly von Willebrand disease), endometrial polyps, and submucosal fibroids 2
• Chronic anovulation can lead to irregular bleeding, prolonged unopposed estrogen stimulation of the endometrium, and increased risk of endometrial cancer, with causes including polycystic ovary syndrome, uncontrolled diabetes mellitus, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics 2
• The acronym PALM-COEIN facilitates classification of abnormal uterine bleeding, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified) 3

Treatments for Menorrhagia

• Medical management is the first-line approach for treating menorrhagia, with options including:
  • Levonorgestrel-releasing intrauterine system (LNG-IUS) 4, 2, 3, 5
  • Combined oral contraceptives 4, 2, 3
  • Continuous oral progestins 4, 3
  • Tranexamic acid 4, 2, 3, 6
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 4, 2, 3
• Surgical options are available for women who do not respond to medical management or have significant structural causes, including:
  • Hysterectomy 2, 3, 5
  • Endometrial ablation 3, 5
  • Polypectomy 2, 3
  • Uterine artery embolization 2, 3
• Emergency interventions for severe bleeding that causes hemodynamic instability include uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization 3