What is the appropriate management for menorrhagia?

Management of Menorrhagia

The first-line treatment for menorrhagia should be medical therapy, with levonorgestrel intrauterine device (LNG-IUD), tranexamic acid, or non-steroidal anti-inflammatory drugs (NSAIDs) as the preferred options, before considering surgical interventions. 1, 2

Diagnostic Approach

Initial Assessment

• Exclude pregnancy as the first step
• Evaluate for anemia (hemoglobin, MCV, ferritin)
• Assess bleeding severity using pictorial blood loss assessment charts (80% sensitivity and specificity for detecting menorrhagia) 3
• Screen for coagulation disorders (especially von Willebrand disease)

Required Investigations

• Pelvic ultrasound to identify structural causes:
  • Uterine fibroids
  • Endometrial polyps
  • Adenomyosis
  • Endometrial hyperplasia
• Endometrial biopsy for women >45 years or with risk factors for endometrial cancer 3, 2
• Consider sonohysterography or hysteroscopy if polyps or submucosal fibroids are suspected 2

Etiological Classification

1. Structural abnormalities (50% of cases)

   • Uterine fibroids
   • Endometrial polyps
   • Adenomyosis
   • Endometrial hyperplasia/cancer

2. Functional disorders (50% of cases)

   • Dysfunctional uterine bleeding
   • Disorders of hemostasis (von Willebrand disease)
   • Hormonal imbalances

Treatment Algorithm

First-Line Treatments

1. Iron Supplementation

   • For all patients with iron deficiency anemia
   • Ferrous sulfate 200 mg three times daily 3, 4
   • Continue for three months after correction of anemia to replenish iron stores
   • Add ascorbic acid to enhance iron absorption 4
   • Monitor response: hemoglobin should rise by 2 g/dL after 3-4 weeks 4

2. Medical Management Options

   • Levonorgestrel intrauterine device (LNG-IUD)

     • Effectiveness comparable to endometrial ablation or hysterectomy 2
     • Suitable for long-term use
     • Can be used for women with and without future pregnancy intention

   • Tranexamic acid

     • Reduces menstrual blood loss by 20-60% 2
     • Antifibrinolytic agent that prevents breakdown of blood clots
     • Taken during menstrual period only

   • Non-steroidal anti-inflammatory drugs (NSAIDs)

     • Reduces menstrual blood loss by 20-60% 2
     • Example: Mefenamic acid
     • Taken during menstrual period only

   • Combined oral contraceptives

     • Effective for menorrhagia control 5
     • Provides contraceptive benefit
     • Regular cyclic withdrawal bleeding

Second-Line Treatments

For patients who fail medical management:

1. For women desiring future pregnancy:

   • Hysteroscopic polypectomy (if polyps present)
   • Hysteroscopic myomectomy (if submucosal fibroids present)
   • Laparoscopic/abdominal myomectomy (if intramural fibroids present) 6

2. For women not desiring future pregnancy:

   • Endometrial ablation techniques
   • Uterine artery embolization (for fibroids)
   • Hysterectomy (definitive treatment) 7, 6

Special Considerations

Specific Structural Causes

• Endometrial polyps: Hysteroscopic polypectomy, can be followed by LNG-IUD 6
• Submucosal fibroids: Hysteroscopic myomectomy 6
• Intramural fibroids: Medical management first, then myomectomy or uterine artery embolization 6
• Adenomyosis: Medical management first (LNG-IUD most effective), then hysterectomy if failed and no pregnancy desired 6

Monitoring and Follow-up

• Monitor hemoglobin and iron studies after 4 weeks of treatment
• Continue iron therapy for three months after correction of anemia 3, 4
• Resolution of anemia should be achieved in 80% of patients by six months 4
• Follow up every three months for one year, then annually 3

Common Pitfalls and Caveats

1. Failure to investigate underlying causes

   • All women >45 years with menorrhagia should have endometrial sampling to exclude malignancy 2
   • Pelvic ultrasound is essential, not optional

2. Inadequate iron replacement

   • Common reasons for inadequate response: poor compliance, continued blood loss, malabsorption 4
   • Consider parenteral iron for severe anemia or when oral therapy fails

3. Premature surgical intervention

   • Medical therapy should be tried and evaluated before considering surgical options 2
   • Many women can avoid surgery with appropriate medical management

4. Overlooking coagulation disorders

   • Up to 20% of women with severe menorrhagia may have underlying bleeding disorders

5. Inadequate follow-up

   • Monitor iron parameters every 3 months for the first year after normalization 4
   • Continue monitoring every 6-12 months if risk factors persist

By following this structured approach to diagnosis and treatment, most women with menorrhagia can achieve significant improvement in symptoms and quality of life, often avoiding surgical intervention.