From the Guidelines
Heavy menstrual bleeding, also known as menorrhagia, should be managed with a thorough history, physical examination, and laboratory tests to rule out underlying causes, and first-line medical treatments should include hormonal options like combined oral contraceptives or levonorgestrel intrauterine system, as these have been shown to be effective in reducing bleeding and improving quality of life 1.
Causes of Menorrhagia
The causes of menorrhagia can be varied and include:
- Fibroids
- Polyps
- Adenomyosis
- Coagulopathies
- Other underlying medical conditions It is essential to rule out these underlying causes through a thorough history, physical examination, and laboratory tests.
Management of Menorrhagia
The management of menorrhagia should be individualized based on the patient's age, desire for fertility, underlying pathology, and personal preferences.
- First-line medical treatments include:
- Hormonal options like combined oral contraceptives (30-35 mcg ethinyl estradiol daily for 21 days followed by 7 days off)
- Levonorgestrel intrauterine system (Mirena, which reduces bleeding by 80-97% over 12 months)
- Cyclic oral progestins (medroxyprogesterone acetate 10 mg daily for 10-14 days per month)
- Non-hormonal options include:
- Tranexamic acid (1000-1300 mg three times daily during menses)
- NSAIDs like ibuprofen (600 mg every 6 hours during menses) For women who have completed childbearing or have failed medical therapy, surgical options include endometrial ablation or hysterectomy. Iron supplementation (325 mg ferrous sulfate three times daily) is often necessary to treat or prevent anemia in women with heavy menstrual bleeding 1.
Recent Guidelines
Recent guidelines from the US Selected Practice Recommendations for Contraceptive Use, 2024, recommend that if clinically indicated, consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids) 1. If an underlying health condition is found, treat the condition or refer for care. The guidelines also provide treatment options for bleeding irregularities while using contraception, including NSAIDs, hormonal treatment, and antifibrinolytic agents like tranexamic acid 1.
Quality of Life
The goal of treatment for menorrhagia is to improve the patient's quality of life by reducing bleeding and alleviating symptoms. Treatment should be individualized based on the patient's preferences, medical history, and underlying pathology. By providing effective treatment options and addressing underlying causes, healthcare providers can help improve the quality of life for women with menorrhagia 1.
From the Research
Causes of Menorrhagia
- Underlying uterine pathologies, coagulopathy, ovulation dysfunction, or iatrogenic factors can cause menorrhagia 2
- Up to 20% of women with menorrhagia will have an underlying inherited bleeding disorder (IBD) 2
- Disorders of coagulation, such as those associated with anticoagulation therapy, can also contribute to menorrhagia 3
Assessment of Menorrhagia
- A menstrual and gynaecological history and a bleeding score can help distinguish those women who require additional haematological investigations 2
- A pelvic examination and ultrasound scan can help rule out the presence of any underlying pathology 2
- Laboratory assessment for anemia, ovulatory dysfunction, underlying bleeding disorder, and over anticoagulation (in the case of patients on anticoagulation) may be necessary 3
Medical Management of Menorrhagia
- The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective treatment for menorrhagia due to endometrial dysfunction and some structural causes (leiomyomas and adenomyosis) 4
- Combined hormonal contraceptives (oral or transvaginal) and tranexamic acid are also effective treatments for menorrhagia 4, 2, 5
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and short-course oral progestogens may be sufficient for women with marginally increased blood loss 4
- Antifibrinolytic agents, such as tranexamic acid, can reduce heavy menstrual bleeding by inhibiting fibrinolysis 6