Medications for Menorrhagia
The first-line medications for menorrhagia include nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, hormonal contraceptives (particularly progestin-only options), and levonorgestrel intrauterine devices (LNG-IUD). These treatments target different aspects of the menstrual cycle to reduce bleeding volume and improve quality of life.
First-Line Pharmacological Options
NSAIDs
- Mechanism: Inhibit prostaglandin synthesis in the endometrium
- Dosing: Ibuprofen 400mg every 4-6 hours during menstruation 1
- Efficacy: Reduces blood loss by 25-39% 2
- Best for: Women with menorrhagia who also experience dysmenorrhea
- Evidence: Clinical studies show ibuprofen reduces elevated prostaglandin activity in menstrual fluid and decreases uterine contractions 1
Tranexamic Acid
- Mechanism: Antifibrinolytic that inhibits plasminogen activation
- Dosing: Taken for 4-5 days starting from first day of menstrual cycle
- Efficacy: Reduces blood loss by approximately 50% 2
- Best for: Women with heavy bleeding who don't need contraception
- Evidence: More effective than NSAIDs for blood loss reduction 3, 4
Hormonal Options
Progestin-Only Contraceptives (POCs)
- Mechanism: Thin the endometrial lining and reduce bleeding
- Options:
- Progestin-only pills
- Depot medroxyprogesterone acetate (DMPA) injections
- Implants
- Best for: Women with menorrhagia who also need contraception
- Evidence: POCs are specifically useful in treating menorrhagia in women with severe thrombocytopenia 5
Levonorgestrel Intrauterine Device (LNG-IUD)
- Mechanism: Local release of progestin thins endometrium
- Efficacy: Can lighten or eliminate menstrual bleeding
- Best for: Long-term management of menorrhagia, especially in women desiring contraception
- Evidence: Highly effective with typical failure rate of 0.1-0.2% 2
Combined Oral Contraceptives (COCs)
- Mechanism: Suppress ovulation and thin endometrium
- Benefits: Regulate menstrual cycle, lessen menorrhagia, reduce anemia
- Cautions: Not first-line for women with cardiovascular risk factors
- Evidence: Effective for menorrhagia but should be avoided in women with certain conditions including history of VTE 5
Treatment Algorithm
Initial Assessment:
- Rule out structural causes (fibroids, polyps)
- Check for coagulation disorders
- Evaluate anemia severity
For women NOT requiring contraception:
- First choice: NSAIDs during menstruation
- If inadequate response: Add tranexamic acid
- If still inadequate: Consider hormonal options
For women requiring contraception:
- First choice: LNG-IUD (most effective for both purposes)
- Alternatives: POCs (pills, DMPA, implants)
- If no contraindications: COCs may be considered
For women with severe thrombocytopenia:
Important Considerations
- Continuous administration of progestational agents is preferred over combined oral contraception for menorrhagia during thrombocytopenic periods 5
- Medroxyprogesterone acetate is preferable for patients with high risk of venous embolism 5
- Progestational agents should not be used >6 months to prevent meningioma occurrence 5
- Women of reproductive age using anticoagulants may experience exacerbated abnormal uterine bleeding 5
- Response to hormonal treatments may take 2-3 months to achieve full effect 5
Monitoring and Follow-up
- Monitor hemoglobin/hematocrit if heavy bleeding continues
- Follow up within 4-6 weeks if bleeding persists despite treatment
- Consider switching medication class if inadequate response after 3 months
- Evaluate for surgical options if medical management fails
Medical management of menorrhagia should be attempted before considering surgical interventions like endometrial ablation or hysterectomy, as effective medications can significantly improve quality of life while avoiding surgical risks.