What are the treatment options for a patient experiencing menorrhagia (heavy menstrual flow)?

Management of Heavy Menstrual Bleeding (Menorrhagia)

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the first-line treatment for heavy menstrual bleeding, providing a 71-95% reduction in menstrual blood loss. 1

Diagnostic Approach

• Rule out pregnancy with pregnancy test
• Evaluate for underlying causes:
  • Structural causes (PALM): Polyps, Adenomyosis, Leiomyoma (fibroids), Malignancy
  • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified
• Laboratory tests should include:
  • Complete blood count (to assess anemia)
  • Thyroid function tests
  • Prolactin levels
  • Consider coagulation studies if bleeding disorder suspected
• Imaging:
  • Transvaginal ultrasonography for structural evaluation
  • Consider saline infusion sonohysterography for better visualization of endometrial cavity
• Endometrial biopsy for women ≥35 years with risk factors or recurrent anovulation

Treatment Algorithm

First-Line Therapy

1. Levonorgestrel-releasing intrauterine system (LNG-IUS)
   • Mirena (20 μg/day): Most effective with 71-95% reduction in blood loss 1
   • Kyleena (14 μg/day): Less documented evidence for menstrual bleeding control 1

Second-Line Options

1. Combined hormonal contraceptives

   • Effective for reducing menstrual blood loss
   • Can be used in extended or continuous regimens 1

2. Tranexamic acid

   • 26-60% reduction in menstrual blood loss
   • Take only during menstruation
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

3. NSAIDs

   • 20-60% reduction in menstrual blood loss 2, 3
   • Recommended dose: 400-800 mg every 4-6 hours as needed
   • Short-term use during menstruation (5-7 days) 4, 1
   • Less effective than tranexamic acid 3

Third-Line Options

1. Oral progestins
   • Less effective than LNG-IUS or combined hormonal contraceptives
   • Useful when estrogen is contraindicated
   • 21-day regimen per month is recommended 1

Management of Specific Bleeding Patterns with Contraceptives

For women using contraceptives who experience bleeding irregularities:

• Cu-IUD users: NSAIDs for 5-7 days
• LNG-IUD users: NSAIDs for 5-7 days
• Implant users: NSAIDs for 5-7 days
• Injectable users: NSAIDs for 5-7 days or hormonal treatment with COCs if medically eligible 4

Surgical Options (for treatment failure)

1. Uterine Artery Embolization (UAE)

   • Effective for heavy menstrual bleeding associated with fibroids
   • Causes >50% decrease in fibroid size at 5 years
   • Less invasive than hysterectomy with shorter hospital stays 4
   • Side effects include pelvic pain, post-embolization syndrome, and fibroid expulsion

2. Endometrial ablation

   • For women with completed childbearing who fail medical management
   • Less invasive alternative to hysterectomy
   • Potential complications include delayed diagnosis of endometrial cancer, post-ablation syndrome, uterine perforation 1

3. Hysterectomy

   • Definitive treatment but most invasive option
   • Consider only when less invasive procedures are unavailable or unsuccessful
   • Associated with increased risk of cardiovascular disease, mood disorders, and longer recovery time 4
   • Should be performed via least invasive route possible (vaginal or laparoscopic preferred over abdominal) 4

Important Considerations

• Evaluate treatment efficacy after 3-6 months; consider alternative options if inadequate response
• For women with fibroids, UAE is equally effective as myomectomy for reducing heavy menstrual bleeding at 4 years 4
• Women with no desire for future fertility should be counseled that pregnancy is still possible after UAE 4
• Treatment failure of endometrial ablation has been associated with the presence of adenomyosis 4
• NSAIDs may increase cardiovascular risk with long-term use; limit to short-term treatment during menstruation 1
• Tranexamic acid should be avoided in women with history of thromboembolic disease 1

The choice of therapy should be guided by the underlying cause of bleeding, desire for contraception, future fertility plans, and presence of contraindications to specific treatments.