What are the treatment options for heavy menstrual bleeding?

Treatment Options for Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective treatment for heavy menstrual bleeding, reducing blood loss by 40-50% and inducing amenorrhea in many users. 1

First-Line Treatment Options

Hormonal Options

• Levonorgestrel-releasing intrauterine device (LNG-IUD)

  • Most effective option for reducing menstrual blood loss
  • Reduces bleeding by 40-50% 1
  • Particularly useful for women with severe thrombocytopenia 2
  • Provides contraception for up to 5 years 1
  • No increased risk of thromboembolism 1

• Combined hormonal contraceptives (CHCs)

  • Effective for reducing heavy menstrual bleeding 3
  • Available as pills, vaginal rings, or patches
  • Moderate-quality evidence shows CHCs can increase successful treatment from 3% to 77% compared to placebo 3
  • Less effective than LNG-IUD but still a viable option 3
  • Consider higher estrogen content (30-35 μg ethinyl estradiol) for better control of breakthrough bleeding 1

• Progestin-only options

  • Oral progestins
  • Injectable progestins (DMPA)
  • Typical failure rate of 5-9% for pills 1

Non-hormonal Options

• Tranexamic acid

  • Antifibrinolytic that can effectively reduce bleeding 4
  • Can be used in both oral and intravenous forms for acute bleeding 4
  • Can be combined with hormonal methods 5

• NSAIDs (e.g., mefenamic acid, naproxen)

  • May reduce menstrual blood loss 6
  • Can be used in combination with hormonal methods 5
  • Taking NSAIDs (e.g., naproxen 500-550mg) 1 hour before IUD insertion can help reduce discomfort 1

Treatment Algorithm

For Acute Heavy Bleeding

1. Assess hemodynamic stability (orthostatic blood pressure and pulse) 4
2. First-line: Medical management 4
   • Tranexamic acid (oral or IV)
   • High-dose combined hormonal contraceptives
   • IV estrogen for severe cases
3. Second-line: Surgical options (only if medical therapy fails or patient is clinically unstable) 4

For Chronic Heavy Bleeding

1. First-line: LNG-IUD 1

   • Most effective option with minimal side effects
   • Provides long-term management and contraception

2. Alternative first-line options:

   • Combined hormonal contraceptives
   • Tranexamic acid
   • NSAIDs

3. Second-line: Surgical options

   • Endometrial ablation (13% of women in a 10-year follow-up study) 7
   • Hysterectomy (17% of women in a 10-year follow-up study) 7

Special Considerations

Women with Bleeding Disorders

• LNG-IUD is particularly beneficial 1, 4
• Tranexamic acid is effective 4
• All hormonal methods can be used 5

Women with Cardiovascular Disease

• Avoid estrogen-containing contraceptives due to thromboembolism risk 1
• LNG-IUD is the safest option 1

Women with Thrombocytopenia

• LNG-IUD may be particularly useful 2
• Severe thrombocytopenia increases bleeding risk 2

Long-term Outcomes

• In a 10-year follow-up study, only 29% of women with heavy menstrual bleeding required surgical intervention 7
• 43% of women had ceased all medical treatments after 10 years 7
• 43% were using LNG-IUD alone or in combination with other treatments 7

Common Pitfalls and Caveats

• Unexplained vaginal bleeding should be evaluated for underlying pathology before treatment 2
• Breakthrough bleeding is common when starting hormonal contraceptives and typically resolves within 2-3 cycles 1
• Estrogen-containing contraceptives should be avoided in women at high risk for thromboembolic events 1
• No antibiotic prophylaxis is needed for LNG-IUD insertion 1
• Vasovagal reactions occur in approximately 5% of patients during IUD insertion 1

Remember that medical management is the first-line approach for heavy menstrual bleeding, with surgical options reserved for those who don't respond to medical therapy.