What are the treatment options for menometrorrhagia?

Treatment Options for Menometrorrhagia

All patients with menometrorrhagia should receive iron supplementation to correct anemia and replenish body stores, with oral ferrous sulfate 200mg three times daily being the most effective first-line treatment. 1

Diagnostic Approach

Before initiating treatment, it's essential to determine the underlying cause:

1. Rule out pregnancy first with hCG testing 2
2. Laboratory assessment:
   • Complete blood count (to assess anemia)
   • Ferritin levels (to assess iron stores)
   • Coagulation studies (prothrombin time, activated partial thromboplastin time)
   • Consider von Willebrand testing, especially in adolescents 3
3. Imaging:
   • Pelvic ultrasound (transvaginal preferred) to identify structural abnormalities 2
4. Tissue sampling:
   • Endometrial biopsy to rule out endometrial cancer, especially in women over 45 2

Treatment Algorithm

First-Line Medical Treatments

• Iron supplementation: Ferrous sulfate 200mg three times daily for all patients with iron deficiency 1
• NSAIDs: For short-term treatment (5-7 days) during bleeding episodes 1, 4
• Tranexamic acid: Antifibrinolytic agent effective for heavy bleeding 5, 2

Second-Line Medical Treatments

• Hormonal options:
  • Levonorgestrel intrauterine device (LNG-IUD): Most effective medical treatment for menometrorrhagia with failure rate <1% 4, 2
  • Combined oral contraceptives: For women without contraindications 4, 6
  • Progestin-only pills: Especially suitable for women with contraindications to estrogen 4
  • GnRH agonists: For short-term use in severe cases 7

Surgical Options (Based on Underlying Cause)

1. For women desiring future pregnancy:

   • Hysteroscopic polypectomy (for endometrial polyps)
   • Hysteroscopic myomectomy (for submucosal fibroids)
   • Laparoscopic/abdominal myomectomy (for intramural fibroids) 6

2. For women not desiring future pregnancy:

   • Endometrial ablation (for dysfunctional uterine bleeding)
   • Uterine artery embolization (for fibroids)
   • Hysterectomy (definitive treatment for persistent, severe bleeding) 6, 5

Cause-Specific Treatments

Dysfunctional Uterine Bleeding (No Structural Abnormality)

1. Medical management as first line:
   • NSAIDs
   • Tranexamic acid
   • Hormonal treatments (LNG-IUD preferred)
2. Endometrial ablation if medical treatment fails
3. Hysterectomy as last resort 6

Structural Abnormalities

• Endometrial polyps: Hysteroscopic polypectomy, possibly 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 needed 6

Special Considerations

Adolescents

• Most cases are idiopathic or related to anovulatory cycles
• Rule out coagulation disorders, especially von Willebrand disease
• NSAIDs and hormonal treatments (combined oral contraceptives) are first-line treatments 3

Perimenopausal Women

• Higher risk of endometrial pathology
• Endometrial sampling is essential
• LNG-IUD is particularly effective in this population 1, 2

Treatment Monitoring

• Monitor hemoglobin concentration and red cell indices after treatment
• Once normal, check every three months for one year, then after another year
• Continue iron supplementation for three months after correction of anemia 1

Common Pitfalls

• Failing to rule out endometrial cancer in women over 45
• Not addressing underlying iron deficiency
• Inadequate duration of iron therapy (should continue for 3 months after anemia correction)
• Overlooking coagulation disorders, especially in adolescents
• Not considering adenomyosis as a cause of treatment-resistant menometrorrhagia

Remember that hysterectomy, while the most definitive treatment, should be reserved for cases where medical management and less invasive surgical options have failed or are contraindicated.