What are the management options for menorrhagia?

Management of Menorrhagia

Combined oral contraceptives (COCs) should be considered first-line treatment for menorrhagia due to their ability to reduce menstrual blood loss by up to 50% in most women. 1

Definition and Impact

Menorrhagia refers to heavy cyclical menstrual bleeding occurring over several consecutive cycles, objectively defined as menstrual blood loss equal to or greater than 80ml per menstruation. It affects approximately 30% of women and represents a significant healthcare burden, accounting for two-thirds of all hysterectomies 2.

First-Line Treatment Options

Hormonal Options

1. Combined Oral Contraceptives (COCs)

   • Reduce menstrual blood loss by up to 50%
   • Regulate menstrual cycles
   • Maximum benefit may not be seen until after 3 cycles of use
   • Breakthrough bleeding is common in first 3 months but typically improves with continued use 1

2. Progestational Agents

   • For menorrhagia during thrombocytopenic periods, continuous administration of progestational agents is preferred over combined oral contraception 3
   • Medroxyprogesterone acetate is preferable in patients with high risk of venous embolism
   • Should not be used >6 months to prevent meningioma occurrence 3

3. Levonorgestrel Intrauterine System (LNG-IUD)

   • Most effective option, reducing blood loss by up to 96% after 12 months
   • Note: 44% of patients may develop amenorrhea 4

Non-Hormonal Options

1. Tranexamic Acid

   • Dosage: 1.5-3g daily in divided doses for 4-5 days during menstruation
   • Reduces menstrual blood loss by 34-59% over 2-3 cycles 4
   • More effective than NSAIDs, etamsylate, and oral luteal phase norethisterone 4, 5
   • Well-tolerated with primarily gastrointestinal side effects (12% incidence) 4

2. NSAIDs (e.g., Mefenamic Acid)

   • Can be used for short-term treatment (5-7 days) during days of bleeding 3
   • Reduces menstrual blood loss by approximately 20% 5
   • Less effective than tranexamic acid but better than placebo 5

Treatment Algorithm

1. Initial Assessment

   • Rule out underlying gynecological problems (e.g., polyps, fibroids, malignancy)
   • Assess for anemia and hemodynamic stability
   • Consider coagulation disorders (e.g., von Willebrand disease) in severe cases 6

2. First-Line Therapy

   • For women without contraindications: Combined oral contraceptives
   • For women with contraindications to estrogen: Progestational agents or tranexamic acid

3. Second-Line Therapy

   • If first-line therapy fails: Consider LNG-IUD
   • For women who decline hormonal options: Tranexamic acid (1.5-3g daily in divided doses)

4. Refractory Cases

   • Consider surgical options (endometrial ablation or hysterectomy)

Special Considerations

Contraindications to Hormonal Therapy

• Active or history of arterial thromboembolic disease
• Breast cancer or other estrogen/progestin-sensitive cancer
• History of deep vein thrombosis or pulmonary embolism
• Migraine with aura if >35 years of age
• Uncontrolled hypertension
• Smoking if >35 years of age
• Liver disease or tumors 1

For Women with Bleeding Disorders

• Higher doses of tranexamic acid (3g daily in four divided doses) may be effective for menorrhagia in women with von Willebrand disease 6

For Women Using Contraceptive Implants

• If irregular bleeding persists and is unacceptable, consider:
  • NSAIDs for short-term treatment (5-7 days)
  • Hormonal treatment with low-dose COCs for short-term treatment (10-20 days) 3

Monitoring and Follow-up

• Assess response after 3 months of therapy
• Monitor for side effects of medications
• For women with persistent symptoms despite treatment, consider referral for surgical management

Common Pitfalls to Avoid

1. Failing to rule out underlying pathology before initiating treatment
2. Not providing adequate trial period (at least 3 months) for hormonal treatments
3. Underestimating the effectiveness of tranexamic acid as a non-hormonal option
4. Not addressing iron deficiency anemia that may accompany menorrhagia
5. Overlooking the possibility of bleeding disorders in women with severe menorrhagia

Remember that while menorrhagia is common, it significantly impacts quality of life and should be treated promptly and effectively to prevent complications such as anemia and to improve patient well-being.