What are the treatment options for heavy menstrual bleeding?

Treatment Options for Heavy Menstrual Bleeding

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

First-Line Medical Management Options

Hormonal Options:

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

   • Most effective first-line treatment (71-95% reduction in blood loss) 1
   • Mirena (20 μg/day) has stronger evidence for menstrual bleeding control than Kyleena (14 μg/day) 1
   • Provides contraception while treating heavy bleeding

2. Combined hormonal contraceptives

   • Effective for reducing menstrual blood loss 1
   • Can be used in extended or continuous regimens
   • Good option for women who also need contraception 1
   • Can be taken cyclically or continuously

3. Oral progestins

   • Effective when given for 21 days per month 1
   • Option when estrogen is contraindicated
   • Less effective than LNG-IUS or combined hormonal contraceptives 1

Non-hormonal Options:

1. Tranexamic acid

   • Provides 26-60% reduction in menstrual blood loss 1, 2
   • Take only during menstruation 1
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1, 2

2. Non-steroidal anti-inflammatory drugs (NSAIDs)

   • Ibuprofen: 400 mg every 4-6 hours as needed for dysmenorrhea 3
   • Naproxen: Effective for menstrual pain relief 4
   • Recommended for short-term treatment (5-7 days) during menstruation 1
   • May increase cardiovascular risk with long-term use 1
   • Less effective than other options but can be combined with hormonal methods 5

Treatment Algorithm Based on Patient Factors

For women desiring contraception:

• First choice: LNG-IUS (Mirena) 1, 6
• Alternative: Combined hormonal contraceptives 1

For women not desiring contraception:

• First choice: Tranexamic acid during menstruation 1, 2
• Alternative: Cyclic oral progestins 1

For perimenopausal women:

• First choice: Cyclic progestin or cyclic estrogen with progestin 1
• Alternative: LNG-IUS if structural abnormalities are ruled out 1

For women with contraindications to hormonal therapy:

• First choice: Tranexamic acid (unless contraindicated) 1, 2, 7
• Alternative: NSAIDs during menstruation 1, 3, 4

Second-Line Options (After Failed Medical Management)

If medical management fails after 3-6 months of adequate trial, consider:

1. Endometrial ablation

   • Less invasive alternative to hysterectomy 1
   • Preserves the uterus with fewer complications 1
   • Good option for women who have completed childbearing 1

2. Hysterectomy

   • Definitive treatment for refractory cases 1
   • Consider when other treatments have failed 1
   • Appropriate when significant intracavitary lesions are present 1

Important Considerations and Pitfalls

• Diagnostic approach: Use the PALM-COEIN classification system to identify structural (PALM) and non-structural (COEIN) causes before treatment 1
• Laboratory evaluation: Complete blood count for anemia, thyroid function tests, and prolactin levels should be performed 1
• Imaging: Transvaginal ultrasound to evaluate for structural causes 1
• Age consideration: Endometrial biopsy for women ≥35 years with recurrent anovulation or risk factors 1
• Monitoring: Evaluate treatment response after 3-6 months before considering alternative options 1
• Combination therapy: NSAIDs may be utilized with hormonal methods and tranexamic acid to enhance effectiveness 5

Remember that heavy menstrual bleeding significantly impacts quality of life, and effective treatment can substantially improve women's physical, social, and leisure activities 8. The PALM-COEIN classification helps guide appropriate treatment selection based on the underlying cause of bleeding.