What is the initial treatment for menorrhagia?

Initial Treatment for Menorrhagia

The initial treatment for menorrhagia should be NSAIDs for 5-7 days during menstruation, with ibuprofen 400-800 mg three times daily being the first-line medical therapy. 1, 2

Diagnostic Approach Before Treatment

Before initiating treatment, consider:

• Rule out underlying gynecological problems:

  • Polyps, fibroids, endometrial hyperplasia, or cancer
  • Interactions with medications
  • Sexually transmitted infections
  • Pregnancy complications

• Basic laboratory testing:

  • Complete blood count to assess anemia
  • Ferritin levels to evaluate iron stores
  • Pregnancy test to rule out pregnancy-related bleeding
  • Thyroid function tests

• Imaging as indicated:

  • Transvaginal ultrasound if bleeding pattern has changed substantially or anemia is present 2

Treatment Algorithm

First-Line Treatments:

1. NSAIDs (5-7 days during menstruation)

   • Ibuprofen 400-800 mg three times daily 1
   • Reduces menstrual blood loss by 20-60% 3
   • Mechanism: Inhibits prostaglandin synthesis in the endometrium 1

2. Tranexamic acid (alternative first-line)

   • 1.5g three times daily for 5 days during menstruation 4
   • Reduces menstrual blood loss by 34-59% 4
   • More effective than NSAIDs in some studies 4

Second-Line Treatments (if first-line fails):

1. Hormonal options:

   • Levonorgestrel intrauterine system (LNG-IUD)

     • Effectiveness comparable to endometrial ablation or hysterectomy 3
     • Significant reduction in menstrual blood loss 5

   • Combined hormonal contraceptives

     • For women without contraindications to estrogen 5

   • Progestin-only options (if estrogen is contraindicated)

     • Oral progestins
     • Injectable contraception (DMPA) 5

Special Considerations

• For women with severe thrombocytopenia:

  • Progestin-only contraceptives may be useful in treating menorrhagia 2
  • Caution with DMPA due to increased or erratic bleeding on initiation and irreversibility for 11-13 weeks 2

• For women with cardiovascular risk factors:

  • Avoid estrogen-containing methods 5
  • Consider progestin-only options 5

• For women desiring contraception:

  • LNG-IUD provides both menorrhagia treatment and contraception 5
  • Combined hormonal methods or progestin-only methods can address both needs 5

Follow-Up

• Monitor hemoglobin and ferritin levels after 3 months of treatment
• If anemia is present, continue iron supplementation for three months after correction of anemia to replenish iron stores 2
• If initial treatment fails after 3 months, consider moving to second-line therapy

Common Pitfalls

• Failure to treat underlying anemia: Iron supplementation should be given alongside menorrhagia treatment if anemia is present 2

• Inadequate treatment duration: NSAIDs and tranexamic acid must be taken for the full 5-7 days during menstruation to be effective 2

• Overlooking structural causes: Approximately 50% of menorrhagia cases have underlying pathology such as fibroids or polyps 6

• Delaying effective treatment: Drug treatment should be used and evaluated before surgical interventions are considered 3

• Inappropriate use of cyclic progestogens: These do not significantly reduce menstrual bleeding in women who ovulate 3

By following this treatment algorithm, most women with menorrhagia can achieve significant improvement in their symptoms and quality of life without requiring surgical intervention.