What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

The most effective treatments for menorrhagia include hormonal options like the levonorgestrel-releasing intrauterine device (LNG-IUD), non-steroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, and surgical interventions such as endometrial ablation or hysterectomy, with treatment selection based on underlying cause, severity, and fertility desires.

Initial Assessment and Diagnosis

• Definition: Menorrhagia is defined as excessive uterine bleeding occurring at regular intervals or prolonged bleeding lasting more than 7 days, with objective blood loss ≥80 ml per cycle
• Key diagnostic steps:
  • Pelvic examination to identify anatomical causes
  • Vaginal sonography if menstrual pattern has changed or anemia is present
  • Endometrial biopsy to rule out hyperplasia or carcinoma
  • Sonohysterography or hysteroscopy to diagnose polyps and fibroids

Medical Treatment Options

First-Line Therapies

1. Levonorgestrel-releasing intrauterine system (LNG-IUD)

   • Effectiveness comparable to endometrial ablation or hysterectomy 1
   • Particularly useful for treating menorrhagia in women with severe thrombocytopenia 2
   • Preserves fertility while providing effective treatment

2. Tranexamic acid

   • Reduces menstrual blood loss by 20-60% 1
   • Antifibrinolytic agent that helps control bleeding
   • Can be used for acute management of heavy bleeding episodes

3. NSAIDs (e.g., mefenamic acid, ibuprofen)

   • Reduces menstrual blood loss by 20-60% 1
   • For dysmenorrhea, ibuprofen 400 mg every 4 hours as needed 3
   • Works by inhibiting prostaglandin synthesis

4. Combined oral contraceptives

   • Effective for regulating menstrual cycles and reducing bleeding
   • Particularly useful in younger women without contraindications

Second-Line Therapies

1. Progestin-only contraceptives

   • Progestin-only pills (POPs) may be useful in treating menorrhagia 2
   • Depot medroxyprogesterone acetate (DMPA) should be used with caution due to initial irregular bleeding 2
   • Continuous progestins more effective than cyclic administration in ovulating women 1

2. GnRH agonists

   • Effective for short-term treatment
   • Useful for preoperative reduction of fibroid size
   • Limited by side effects with long-term use (bone loss)

Surgical Treatment Options

Uterine-Preserving Procedures

1. Endometrial ablation

   • High satisfaction rates for women who have completed childbearing 4
   • Various techniques: thermal balloon, radiofrequency, microwave, cryotherapy
   • Less invasive than hysterectomy with shorter recovery time

2. Myomectomy

   • Appropriate for women with fibroids who wish to preserve fertility
   • Can be performed hysteroscopically, laparoscopically, or via laparotomy
   • 23-33% recurrence rate 2

3. Uterine artery embolization (UAE)

   • Alternative to surgery for fibroid-related menorrhagia
   • Shorter hospital stay and decreased blood loss compared to hysterectomy 2
   • Higher reintervention rates compared to myomectomy (36% vs 5%) 2

Definitive Treatment

1. Hysterectomy
   • Highest satisfaction rates if fertility preservation not desired 4
   • Definitive treatment with no risk of recurrence
   • Consider potential surgical morbidity and recovery time

Treatment Algorithm Based on Underlying Cause

Idiopathic Menorrhagia (No Structural Abnormalities)

1. Start with medical therapy: LNG-IUD, tranexamic acid, or NSAIDs
2. If unsuccessful after 3-6 months, consider endometrial ablation
3. Hysterectomy as last resort if other treatments fail

Fibroid-Related Menorrhagia

1. Medical therapy with LNG-IUD or GnRH agonists
2. Consider UAE or myomectomy if fertility preservation desired
3. Hysterectomy if definitive treatment preferred and childbearing complete

Polyp or Intracavitary Lesions

1. Hysteroscopic removal of polyps
2. Follow with LNG-IUD or medical therapy if bleeding persists

Bleeding Disorders (e.g., Thrombocytopenia)

1. Progestin-only contraceptives may be useful 2
2. LNG-IUD particularly effective for menorrhagia with thrombocytopenia 2
3. Caution with DMPA due to unpredictable bleeding patterns 2

Special Considerations

• Adolescents: Prefer medical management; surgical options rarely indicated
• Perimenopausal women: Rule out endometrial hyperplasia/cancer before treatment
• Women with thrombocytopenia: LNG-IUD or progestin-only methods recommended 2
• Women undergoing chemotherapy: Continuous progestational agents preferred over combined oral contraception, especially during prothrombotic states 2

Treatment Effectiveness

• LNG-IUD: Comparable to surgical interventions with fewer risks
• NSAIDs and tranexamic acid: 20-60% reduction in blood loss
• Endometrial ablation: 80-90% reduction in blood loss
• Hysterectomy: 100% effective but with potential surgical complications

By following this treatment approach, most women with menorrhagia can achieve significant improvement in symptoms and quality of life.