What are the management options for increased menstrual bleeding?

Management Options for Increased Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the first-line medical therapy for heavy menstrual bleeding, with combined hormonal contraceptives as the second choice for women not seeking pregnancy. 1

Diagnostic Approach

Before initiating treatment, it's essential to determine the cause of increased menstrual bleeding using the PALM-COEIN classification system:

• Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy/hyperplasia
• Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 2

Diagnostic tests should include:

• Pregnancy test
• TSH and prolactin levels
• Endometrial biopsy (for women ≥35 years with recurrent anovulation or risk factors)
• Transvaginal ultrasonography or saline infusion sonohysterography for structural evaluation 2

Treatment Algorithm

First-Line Treatments

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

   • Most effective medical treatment, reducing menstrual blood loss by 71-95% 3
   • Mirena (20 μg/day) has comparable efficacy to endometrial ablation 3
   • Lower-dose Kyleena (14 μg/day) may offer advantages for women concerned about systemic hormone exposure 3

2. Combined hormonal contraceptives (oral or transvaginal)

   • Second most effective option
   • Particularly useful for women who also desire contraception 1

3. Tranexamic acid

   • Effective non-hormonal option
   • Contraindicated in women with thromboembolic disease 3

4. NSAIDs (5-7 days of treatment)

   • Less effective than other options but may be sufficient for marginally increased blood loss
   • Can be used in combination with hormonal methods 2

For Specific Scenarios

For Ovulatory Dysfunction

• Progestin-only contraception
  • Oral progestins for 21 days per month are effective 2
  • Cyclic oral progestins (≤14 days per cycle) are less effective 1

For Women with Fibroids

• Medical management options:
  • LNG-IUS is effective for fibroids causing heavy bleeding 2
  • If medical management fails, consider myomectomy, MRI-guided focused ultrasound, or uterine artery embolization 2

For Women on Antiplatelet Therapy

• LNG-IUS (first-line)
• Endometrial ablation (if LNG-IUS insufficient)
• Avoid tranexamic acid and NSAIDs due to increased risk of thrombosis 2

For Secondary Amenorrhea

• Oral progesterone capsules
  • 400 mg daily at bedtime for 10 days 4
  • Effective in inducing withdrawal bleeding in approximately 80% of women 4

When Medical Management Fails

If medical treatment fails or is contraindicated:

1. Endometrial ablation

   • For women who have completed childbearing
   • Contraindicated in women desiring future fertility 3

2. Surgical options

   • Polypectomy or fibroidectomy for structural causes
   • Uterine artery embolization for fibroids
   • Hysterectomy as definitive treatment 5

Important Considerations

• Initial 3-6 months of LNG-IUS use may include unscheduled spotting or light bleeding, which typically improves after this period 3
• For breakthrough bleeding with LNG-IUS, short-term NSAID therapy (5-7 days) may help manage symptoms 3
• Women with heavy bleeding should be evaluated for anemia and treated appropriately
• For women with completed childbearing who fail medical management, endometrial ablation offers uterine preservation with fewer complications compared to hysterectomy 3

By following this algorithm and selecting the appropriate treatment based on the underlying cause and patient factors, most cases of increased menstrual bleeding can be effectively managed with medical therapy, potentially avoiding surgical intervention.