What are the treatment options for heavy menstrual bleeding?

Treatment Options for Heavy Menstrual Bleeding

The first-line treatments for heavy menstrual bleeding include NSAIDs, tranexamic acid, hormonal methods (particularly the levonorgestrel intrauterine device), and surgical options, with selection based on underlying cause, patient preferences, and contraceptive needs. 1

Initial Evaluation

Before initiating treatment, it's essential to:

• Rule out underlying conditions such as:

  • Medication interactions
  • Sexually transmitted infections
  • Pregnancy
  • Thyroid disorders
  • Uterine pathology (polyps, fibroids)
  • Bleeding disorders (present in ~90% of women with underlying bleeding disorders) 2

• Consider endometrial sampling in perimenopausal women due to higher risk of endometrial hyperplasia/cancer 1

• Assess for signs suggestive of bleeding disorders:

  • Clots ≥1 inch diameter
  • Low ferritin
  • "Flooding" (changing pad/tampon more than hourly) 2

Medical Treatment Options

Non-Hormonal Options

1. NSAIDs

   • Reduce menstrual blood loss by 26-60%
   • Used for 5-7 days during bleeding days
   • Particularly effective for copper IUD users with heavy bleeding
   • Examples: naproxen, mefenamic acid, ibuprofen 1
   • More effective than placebo but less effective than tranexamic acid or danazol 3

2. Tranexamic acid

   • Reduces menstrual blood loss by approximately 50%
   • Used for 4-5 days starting from the first day of menstrual cycle
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1
   • More effective than NSAIDs 3

Hormonal Options

1. Levonorgestrel Intrauterine Device (LNG-IUD)

   • First-line option for contraception and heavy menstrual bleeding management
   • High efficacy with typical failure rate of 0.1-0.2%
   • Provides long-term relief
   • Recommended for persistent breakthrough bleeding 1
   • Safer option for women with cardiovascular risk factors 1

2. Combined Oral Contraceptives (COCs)

   • Can be used for 10-20 days for heavy/prolonged bleeding
   • Drospirenone-containing COCs are considered a second-line option
   • Typical failure rate of 5-9%
   • Contraindicated in women with history of thrombosis 1

3. Injectable DMPA (Depot Medroxyprogesterone Acetate)

   • Third-line option
   • Often leads to amenorrhea and eliminates dysmenorrhea
   • Failure rate of 0.3-6% 1

4. Progestin-only pills

   • Alternative for women who cannot use estrogen-containing methods
   • Typical failure rate of 5-9% 1

5. Danazol

   • More effective than NSAIDs but causes more adverse events 3
   • Currently not a commonly recommended treatment for HMB due to side effect profile

Surgical and Minimally Invasive Options

For women who have completed childbearing or when medical therapy fails:

1. Minimally invasive hysteroscopic procedures

   • Can be performed in outpatient setting 4

2. Endometrial ablation

   • Second-generation techniques available in outpatient setting
   • Effective for women who have completed childbearing 4

Treatment Algorithm

1. First determine if there's an underlying cause requiring specific treatment

   • If structural abnormality (fibroids, polyps): Consider targeted treatment
   • If bleeding disorder: Consult hematology
   • If on anticoagulation: Assess for over-anticoagulation 2

2. For women desiring contraception:

   • First choice: LNG-IUD (provides both contraception and reduces bleeding by >90%)
   • Alternative: Combined hormonal contraceptives

3. For women not desiring contraception:

   • First choice: Tranexamic acid during menstruation
   • Alternative: NSAIDs during menstruation

4. For women who have completed childbearing with persistent HMB despite medical therapy:

   • Consider endometrial ablation or other surgical options

Common Pitfalls and Caveats

• Failure to identify underlying bleeding disorders: Women with flooding and/or prolonged menses, or HMB accompanied by personal/family history of bleeding should be referred to a hematologist 2

• Inadequate treatment duration: Counseling and reassurance about expected irregular bleeding are recommended during the first 3 months of hormonal contraceptive use 1

• Missing endometrial pathology: If bleeding persists beyond 3 months of treatment, consider alternative contraceptive methods or evaluate for underlying gynecological problems 1

• Inappropriate use of hormonal methods: Blood pressure measurement is required before initiating combined hormonal contraceptives 1

• Contraindications overlooked: Tranexamic acid is contraindicated in women with thromboembolic disease; combined hormonal methods are contraindicated in women with history of thrombosis 1