What are the management options for menorrhagia?

Management of Menorrhagia

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the first-line treatment option for menorrhagia, offering effectiveness comparable to surgical interventions with fewer risks. 1

Diagnostic Approach

• Evaluate for underlying causes:
  • Uterine abnormalities (fibroids, polyps, adenomyosis)
  • Endocrine disorders
  • Coagulopathies
  • Medication side effects
• Perform pelvic examination
• Consider vaginal ultrasound if:
  • Menstrual pattern has changed substantially
  • Anemia is present
• For women >40 years: rule out endometrial hyperplasia/cancer before treatment

Treatment Algorithm

First-Line Medical Management

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

   • Reduces blood loss by 80-90%
   • Particularly useful for women with severe thrombocytopenia 1
   • Comparable effectiveness to surgical interventions

2. Antifibrinolytic agents

   • Tranexamic acid: reduces blood loss by 20-60% 1, 2
   • Take during menstruation only

3. Non-steroidal anti-inflammatory drugs (NSAIDs)

   • Reduce blood loss by 20-60% 1, 2
   • Take during menstruation

4. Hormonal options

   • Combined oral contraceptives
   • Progestin-only pills
   • Continuous progestational agents (preferred for women undergoing chemotherapy) 1
   • Depot medroxyprogesterone acetate (use with caution due to initial irregular bleeding) 1

Second-Line Interventions

For patients who fail medical management:

1. Endometrial ablation

   • Reduces blood loss by 80-90% 1
   • Suitable for women who have completed childbearing
   • Lower complication rate than hysterectomy

2. Uterine artery embolization (UAE)

   • Effective for fibroid-related menorrhagia
   • Clinical success rates of 81-100% 3
   • Shorter hospital stay and decreased blood loss compared to hysterectomy
   • 20-25% symptom recurrence at 5-7 years 3

3. Myomectomy

   • Appropriate for women with fibroids who wish to preserve fertility
   • 23-33% recurrence rate 1

Third-Line Intervention

1. Hysterectomy
   • 100% effective for menorrhagia 1
   • Consider for women who have completed childbearing and failed other treatments
   • Higher complication risk than other options

Special Considerations

Fibroid-Related Menorrhagia

• UAE is an effective option with median uterine and dominant fibroid volume reductions of 35% and 42% respectively 3
• Significant improvement for patients with menorrhagia (83%) at 3 months post-procedure 3
• Complications of UAE are low (<3% major complications) 3
• Follow-up imaging at 3-6 months post-UAE to assess fibroid volume reduction 3

Women of Reproductive Age

• Medical management is preferred
• Be aware that NOACs may exacerbate abnormal uterine bleeding in women of reproductive age 3
• Counsel about potential increased menstrual bleeding with anticoagulants if relevant

Adolescents

• Prefer medical management
• Surgical options rarely indicated 1

Perimenopausal Women

• Rule out endometrial hyperplasia/cancer before treatment 1

Treatment Selection Based on Fertility Desires

• For women desiring future pregnancy:

  • Medical management (LNG-IUD, tranexamic acid, NSAIDs)
  • Myomectomy for fibroids

• For women who have completed childbearing:

  • All options available including endometrial ablation and hysterectomy
  • LNG-IUD remains an excellent first-line option

Pitfalls and Caveats

• Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 2
• Always rule out malignancy in perimenopausal/postmenopausal women before treatment
• UAE may lead to permanent amenorrhea in up to 10% of patients, with higher risk (up to 20%) in women >45 years 3
• Drug treatment should be thoroughly evaluated before surgical interventions are considered 2