What are the treatment options for perimenopausal menorrhagia?

Treatment Options for Perimenopausal Menorrhagia

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the most effective first-line treatment for perimenopausal menorrhagia, offering superior blood loss reduction compared to other medical therapies. 1, 2

First-Line Treatment Options

Levonorgestrel-releasing IUD (LNG-IUD)

• Most effective medical treatment for menorrhagia
• Reduces menstrual blood loss by approximately 90%
• Provides contraception while treating heavy bleeding
• Many women experience amenorrhea or oligomenorrhea by 2 years of use
• Particularly beneficial for women with:
  • Fibroids
  • Adenomyosis
  • Anemia
  • Severe dysmenorrhea

Oral Medications

1. Tranexamic acid

   • Antifibrinolytic that reduces bleeding by 40-50%
   • Taken only during menstruation
   • Non-hormonal option for women who cannot use hormonal treatments

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

   • Reduces blood loss by 20-30%
   • Ibuprofen 600-800mg every 6-8 hours with food for first 24-48 hours
   • Also helps manage dysmenorrhea
   • Can be combined with other treatments

3. Combined oral contraceptives (COCs)

   • Reduces bleeding by 40-50%
   • Provides cycle control and contraception
   • Offers additional benefits:
     • Regularization of cycles
     • Reduction of vasomotor symptoms
     • Protection against endometrial and ovarian cancer
   • Use with caution in women with cardiovascular risk factors

4. Oral progestins

   • Options include medroxyprogesterone acetate (MPA) 5-10mg daily
   • Can be given cyclically (days 15-26) or continuously
   • Continuous regimen more effective than cyclic
   • Safe option for women with contraindications to estrogen 3

5. Injectable progestins

   • Depot medroxyprogesterone acetate (DMPA)
   • Effective for reducing menorrhagia
   • May lead to amenorrhea with continued use
   • Less effective than LNG-IUD but comparable to oral progestins 2

Second-Line Treatment Options

1. Gonadotropin-releasing hormone (GnRH) agonists

   • Creates temporary menopausal state
   • Highly effective for reducing bleeding
   • Limited to short-term use (3-6 months) due to bone density concerns
   • Consider add-back hormone therapy if used longer than 3 months

2. Surgical Options

   • Endometrial ablation

     • Destroys the endometrial lining
     • Effective for women who have completed childbearing
     • Less invasive than hysterectomy

   • Hysterectomy

     • Definitive treatment for menorrhagia
     • Consider when other treatments fail or if there are other indications
     • Total hysterectomy eliminates risk of endometrial cancer

Treatment Algorithm

1. Initial Assessment

   • Rule out malignancy with endometrial biopsy if:
     • Irregular bleeding pattern
     • Age >45 years
     • Failed medical management
     • Risk factors for endometrial cancer
   • Check hemoglobin levels to assess anemia
   • Evaluate for structural causes (fibroids, polyps, adenomyosis)

2. First-line treatment:

   • LNG-IUD if no contraindications and long-term treatment desired
   • Tranexamic acid if hormonal treatments contraindicated
   • Combined oral contraceptives if contraception also desired and no contraindications
   • Oral progestins if estrogen contraindicated

3. If first-line fails after 3-6 months:

   • Try alternative medical therapy
   • Consider endometrial ablation if childbearing complete
   • Consider hysterectomy if other treatments fail and significant impact on quality of life

Special Considerations

• Anemia: Treat with iron supplementation alongside menorrhagia treatment
• Approaching menopause: Consider that spontaneous resolution will occur with menopause
• Contraception needs: LNG-IUD or COCs provide both menorrhagia treatment and contraception
• Structural abnormalities: LNG-IUD effective even with small fibroids (≤12 weeks size) 1

Monitoring and Follow-up

• Assess response to treatment after 3 months
• Monitor hemoglobin levels in women with anemia
• Consider changing treatment if inadequate response after 3-6 months
• Continue contraception until menopause is confirmed (usually around age 50-55)

The evidence strongly supports LNG-IUD as the most effective medical treatment for perimenopausal menorrhagia, with studies showing superior efficacy compared to oral and injectable progestins 2. For women who cannot or prefer not to use an IUD, tranexamic acid and NSAIDs offer effective non-hormonal options, while hormonal options like COCs and progestins provide additional benefits beyond menorrhagia control.