What are the treatment options for managing heavy menorrhagia (excessive menstrual bleeding)?

Management of Heavy Menorrhagia

First-line medical management options including hormonal contraceptives, tranexamic acid, and NSAIDs should be used before considering surgical interventions for heavy menstrual bleeding. 1, 2

Definition and Impact

• Heavy menstrual bleeding (menorrhagia) is defined as excessive cyclical menstrual blood loss (≥80 ml per cycle) occurring over several consecutive cycles
• Affects approximately 30% of women at some point in their lives
• Significantly impacts quality of life, can cause anemia, and is a common reason for gynecological consultations

First-Line Treatment Options

Medical Management

Hormonal Options:

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

   • Most effective medical treatment for heavy menstrual bleeding
   • Reduces bleeding by up to 90%
   • 50% of users experience amenorrhea or oligomenorrhea by 2 years 2
   • Excellent option for women with anemia, severe dysmenorrhea, or abnormal uterine bleeding 2
   • Can be used in women with fibroids (when not significantly distorting the uterine cavity) 1

2. Combined hormonal contraceptives (pills, patch, ring)

   • Recommended as first-line treatment by the American Academy of Family Physicians 2
   • Monophasic pills containing 30-35 μg of ethinyl estradiol recommended for initiation 2
   • Can be used continuously to suppress menstruation and reduce bleeding 2
   • For persistent irregular bleeding, interrupt use for 3-4 days to induce bleeding (no more than once monthly) 2

3. Progestin-only options

   • Oral progestins (cyclical use for 10-12 days per cycle)
   • Progesterone capsules 400 mg daily at bedtime for 10 days can induce withdrawal bleeding in women with secondary amenorrhea 3
   • Note: Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 4

Non-Hormonal Options:

1. Tranexamic acid

   • Reduces menstrual blood loss by 26-60% 5
   • Recommended dose: 3.9-4 g/day for 4-5 days starting from first day of cycle 5
   • More effective than NSAIDs and oral progestins 5
   • Non-hormonal alternative for women who cannot or prefer not to use hormonal treatments
   • Contraindicated in active thromboembolic disease 5

2. NSAIDs (e.g., ibuprofen, mefenamic acid)

   • Reduces bleeding by 20-40% 4, 6
   • Ibuprofen 600-800 mg every 6-8 hours with food for first 24-48 hours of symptoms 2
   • Also helps manage dysmenorrhea
   • Less effective than tranexamic acid but still beneficial for women with marginally increased blood loss 6

Second-Line Treatment Options

Advanced Medical Therapy

1. GnRH agonists and antagonists
   • Effective at reducing bleeding and fibroid volume 1
   • Examples: leuprolide acetate (agonist), elagolix, linzagolix, relugolix (antagonists) 1
   • Can cause hypoestrogenic side effects (hot flashes, bone mineral density loss)
   • Combination treatment with low-dose estrogen and progestin can mitigate side effects 1
   • Often used for short courses to decrease fibroid size before surgery 1

Surgical Options

1. Endometrial ablation

   • For women who have completed childbearing
   • Effective for reducing heavy bleeding not caused by structural abnormalities

2. Hysteroscopic myomectomy

   • Procedure of choice for pedunculated submucosal fibroids <5 cm 1
   • Associated with shorter hospitalization and faster recovery compared to other surgical approaches

3. Uterine artery embolization (UAE)

   • Effective for women with fibroids
   • Preserves the uterus
   • Higher success rate compared to MR-guided focused ultrasound ablation 1

4. Hysterectomy

   • Definitive treatment but most invasive option
   • Should be considered only after failure of medical management and less invasive surgical options 1

Treatment Algorithm Based on Cause

For Idiopathic Heavy Menstrual Bleeding:

1. Start with medical therapy:
   • First choice: LNG-IUD (if appropriate and acceptable)
   • Alternative first choices: Combined hormonal contraceptives, tranexamic acid, or NSAIDs
2. If inadequate response after 3 months, consider changing to another medical option
3. If medical management fails, consider endometrial ablation or hysterectomy

For Fibroid-Related Heavy Bleeding:

1. Medical management:
   • LNG-IUD (if fibroids don't significantly distort cavity)
   • GnRH agonists/antagonists (especially to reduce fibroid size)
2. If medical management fails:
   • Hysteroscopic myomectomy for submucosal fibroids
   • UAE for intramural/subserosal fibroids
   • Laparoscopic or open myomectomy
   • Hysterectomy if childbearing is complete and other options have failed

Monitoring and Follow-up

• Assess response to treatment after 3 months 2
• Monitor for side effects and adherence issues
• For LNG-IUD users, provide reassurance that spotting in first 3-6 months is common and typically decreases with continued use 2

Important Considerations

• Medical therapy should be tried and evaluated before surgical interventions 4
• Transvaginal ultrasound is recommended as initial imaging for diagnosis when menstrual pattern has changed substantially or anemia is present 4
• The PALM-COEIN system helps classify causes as structural or non-structural 2
• Continuous hormonal regimens can reduce or eliminate bleeding and decrease menstrual-related symptoms 2

Heavy menstrual bleeding significantly impacts quality of life but can be effectively managed with appropriate treatment. Starting with medical management and progressing to surgical options only when necessary provides the best approach to controlling symptoms while minimizing risks.