What are the management options for menorrhagia (abnormal uterine bleeding)?

From the Guidelines

Management of abnormal heavy menstrual bleeding should prioritize a systematic approach, starting with proper assessment and treatment of underlying causes, and considering the woman's age, desire for fertility, contraceptive needs, and personal preferences, with first-line medical treatment typically involving hormonal options like combined oral contraceptives or the levonorgestrel intrauterine system, as recommended by the most recent study 1.

Key Considerations

• Initial management should include a thorough history, physical examination, and laboratory tests to rule out underlying causes such as fibroids, polyps, endometriosis, or bleeding disorders.
• First-line medical treatment typically involves hormonal options like combined oral contraceptives (30-35 mcg ethinyl estradiol) taken cyclically or continuously, or the levonorgestrel intrauterine system (Mirena, 20 mcg/day), which reduces bleeding by up to 90% over 3-6 months, as supported by the study 1.
• Non-hormonal options include tranexamic acid (1000-1300 mg three times daily during menses) which reduces bleeding by inhibiting fibrinolysis, or nonsteroidal anti-inflammatory drugs like mefenamic acid (500 mg three times daily during menses) or ibuprofen (600 mg three times daily during menses) which reduce prostaglandin-mediated blood loss.
• For women not responding to these treatments, second-line options include injectable progestins like depot medroxyprogesterone acetate (150 mg every 3 months) or GnRH agonists for short-term use, as mentioned in the study 1.
• Iron supplementation (ferrous sulfate 325 mg daily) should be prescribed for women with anemia.
• Surgical options like endometrial ablation or hysterectomy may be considered for women who have completed childbearing and have failed medical management, as recommended by the study 1.

Treatment Choice

• Treatment choice should be individualized based on the woman's age, desire for fertility, contraceptive needs, underlying medical conditions, and personal preferences.
• The most recent study 1 provides guidance on the management of uterine fibroids, including medical and surgical options.
• The study 1 also discusses the use of selective progesterone receptor modulators for the treatment of uterine fibroids, which may be considered for women who have failed other medical treatments.

From the FDA Drug Label

In patients with primary dysmenorrhea, ibuprofen tablets have been shown to reduce elevated levels of prostaglandin activity in the menstrual fluid and to reduce resting and active intrauterine pressure, as well as the frequency of uterine contractions. The management option for menorrhagia (abnormal uterine bleeding) is ibuprofen, which can help reduce elevated levels of prostaglandin activity in the menstrual fluid and decrease uterine contractions 2.

• The dose for dysmenorrhea is 400 mg every 4 hours as necessary for the relief of pain. Note that the label does not directly address menorrhagia, but it does discuss dysmenorrhea, which is a related condition involving painful menstruation and heavy bleeding.

From the Research

Management Options for Menorrhagia

The management options for menorrhagia (abnormal uterine bleeding) can be divided into medical and surgical treatments.

• Medical management is the first-line approach and includes:
  • Combination oral contraceptives or progestins to regulate menstrual cycles 3
  • Levonorgestrel-releasing intrauterine system, which is an effective treatment for menorrhagia 3, 4
  • Oral progesterone for 21 days per month 3
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease menstrual bleeding 3, 4, 5
  • Tranexamic acid, which is approved by the U.S. Food and Drug Administration for the treatment of ovulatory bleeding 3, 4, 6
  • Gonadotropin-releasing hormone agonists for patients with leiomyoma and abnormal uterine bleeding 4
• Surgical management options include:
  • Polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation when clear structural causes are identified or medical management is ineffective 3
  • Hysterectomy, which is the most definitive treatment 3
  • Minimally invasive surgical procedures, such as endometrial resection and ablation, which may treat menorrhagia in select patients 5
  • Office-based ablation instruments, which conform to the endometrial cavity and may obviate the need for hysteroscopy 5

Considerations for Treatment

The treatment strategy for menorrhagia depends on various factors, including:

• The acuity of the bleeding 4
• The patient's medical history and risk factors 4
• The presence of structural causes, such as uterine pathology or coagulation defects 3, 7
• The patient's desire for fertility 7
• The patient's age and overall health status 7, 6