What are the management options for menorrhagia?

Management Options for Menorrhagia

The most effective management options for menorrhagia include levonorgestrel-releasing intrauterine system (LNG-IUD), tranexamic acid, NSAIDs, endometrial ablation, uterine artery embolization (UAE), and hysterectomy, with the LNG-IUD reducing blood loss by 80-90% as a preferred first-line option for most women. 1

Diagnostic Approach

• Initial evaluation should include:
  • Pelvic examination
  • Vaginal sonography (especially if menstrual pattern has changed or anemia is present)
  • Endometrial biopsy (to rule out hyperplasia/cancer, particularly in perimenopausal women)
  • Laboratory tests: CBC, TSH, pregnancy test

Treatment Algorithm

First-Line Medical Management

1. Levonorgestrel-releasing IUD (LNG-IUD)

   • Reduces blood loss by 80-90%
   • Suitable for women who have completed childbearing and those desiring future pregnancy
   • Comparable effectiveness to endometrial ablation or hysterectomy 1

2. Tranexamic acid

   • Reduces blood loss by 20-60%
   • Take only during menstruation
   • Antifibrinolytic mechanism 1, 2

3. NSAIDs

   • Reduces blood loss by 20-60%
   • Take only during menstruation
   • Particularly effective when menorrhagia is associated with dysmenorrhea 1, 2

4. Hormonal options

   • Combined oral contraceptives
   • Progestin-only contraceptives
   • Continuous progestational agents (preferred for women undergoing chemotherapy) 1

Second-Line and Surgical Options

For patients who fail medical management or have specific pathology:

1. Endometrial ablation

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

2. Uterine Artery Embolization (UAE)

   • Effective for fibroid-related menorrhagia
   • Median uterine volume reduction of 35%
   • Shorter hospital stay and decreased blood loss compared to hysterectomy
   • Clinical success rates of 81-100% 3, 1
   • Caution: May lead to permanent amenorrhea in up to 10% of patients (higher risk up to 20% in women >45 years) 1

3. Myomectomy

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

4. Hysterectomy

   • 100% effective for menorrhagia
   • Definitive therapy for fibroid-related menorrhagia
   • High patient satisfaction (90% report at least moderate satisfaction at 2 years)
   • Consider only after failure of other treatments due to higher complication risk 3, 1

Special Considerations

Fibroid-Related Menorrhagia

• UAE shows 83% improvement in menorrhagia symptoms at 3 months post-procedure 1
• UAE has higher reintervention rates compared to myomectomy (36% vs 5%) 1
• 20-25% symptom recurrence at 5-7 years after UAE, though most women report continued high quality-of-life scores 3
• Location of fibroids affects treatment success (cervical fibroids have higher failure rates with UAE) 3

Age-Related Considerations

• Adolescents: Prefer medical management; surgical options rarely indicated 1
• Perimenopausal women: Rule out endometrial hyperplasia/cancer before treatment 1
• Women <40 years: Higher treatment failure rates with UAE (23% at 10 years) 3

Treatment Pitfalls to Avoid

• Cyclic progestogens are not effective for women who ovulate 2
• Endometrial ablation has uterine cavity size limitations (most devices treat cavities up to 10 cm) 3
• Submucosal fibroids have higher failure rates with endometrial ablation (23% vs 4% for normal uterine cavities) 3
• Women who undergo hysterectomy with ovarian preservation still have nearly twofold increased risk for ovarian failure 3

Follow-up Recommendations

• Follow-up imaging at 3-6 months post-UAE to assess fibroid volume reduction 1
• Monitor for anemia in patients with ongoing heavy bleeding
• Reassess treatment efficacy after 3-6 months and consider alternative options if inadequate response