From the Guidelines
Management of abnormal heavy menstrual bleeding should start with assessment of the underlying cause and first-line treatment typically includes hormonal options such as combined oral contraceptives or non-hormonal options like tranexamic acid. The approach to managing menorrhgia involves several key steps and considerations to prioritize morbidity, mortality, and quality of life. First, it is crucial to assess for any underlying gynecological problems, such as fibroids or polyps, that could be contributing to the heavy bleeding, as identified in studies 1. If an underlying cause is found, treatment should be directed at addressing this condition.
For women without an identifiable underlying cause, first-line treatment options include NSAIDs for short-term relief (5-7 days) or hormonal treatments like low-dose COCs or estrogen for short-term use (10-20 days), as recommended by 1 and 1. Non-hormonal alternatives such as tranexamic acid can also be considered for reducing bleeding, as discussed in 1 and 1.
In cases where medical management is ineffective or the bleeding persists, surgical options like endometrial ablation or hysterectomy may be considered, especially for those who have completed childbearing, as noted in 1. It is also important to address potential anemia with iron supplementation, such as ferrous sulfate 325mg daily, and to advise patients on tracking their bleeding patterns and seeking immediate medical attention for severe symptoms. Given the most recent and highest quality evidence from 1 and 1, which discuss the efficacy of various medical and surgical interventions for managing uterine fibroids and heavy menstrual bleeding, the use of tranexamic acid, NSAIDs, and hormonal treatments, followed by surgical options when necessary, represents a comprehensive approach to managing menorrhgia while prioritizing patient outcomes.
Key considerations in managing menorrhgia include:
- Assessing for underlying causes
- Using first-line treatments such as NSAIDs, hormonal options, or tranexamic acid
- Considering surgical interventions for refractory cases
- Addressing anemia and educating patients on symptom management
- Prioritizing treatments based on the most recent and high-quality evidence, such as that from 1 and 1.
From the Research
Management of Menorrhagia
The management of menorrhagia, or abnormally heavy menstrual bleeding, can be divided into medical and surgical interventions.
- Medical management options include:
- Combination oral contraceptives or progestins to regulate menstrual cycles 2
- The levonorgestrel-releasing intrauterine system (LNG-IUS) to reduce menstrual blood loss 2, 3, 4
- Tranexamic acid, which is approved by the U.S. Food and Drug Administration for the treatment of ovulatory bleeding 2, 3, 5
- Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce prostaglandin levels and alleviate dysmenorrhoea 2, 5
- Oral progesterone for 21 days per month 2
- Surgical interventions may be considered when medical management is ineffective or when clear structural causes are identified, and include:
Evaluation of Menorrhagia
Evaluation of menorrhagia may involve:
- Transvaginal ultrasonography or saline infusion sonohysterography to identify structural causes such as endometrial polyps or submucosal fibroids 2
- Endometrial biopsy to assess for hyperplasia or cancer, particularly in women 35 years or older with recurrent anovulation or risk factors for endometrial cancer 2
Effectiveness of Treatments
The effectiveness of treatments for menorrhagia can vary, with:
- The LNG-IUS being the most effective medical treatment for reducing menstrual blood loss 3, 4
- Tranexamic acid being less effective than the LNG-IUS but more effective than NSAIDs 3, 5
- NSAIDs being less effective than tranexamic acid, danazol, or the LNG-IUS, but still reducing menstrual blood loss compared to placebo 5