What are the treatment options for menorrhagia (heavy menstrual bleeding)?

Treatment Options for Menorrhagia (Heavy Menstrual Bleeding)

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the first-line treatment for menorrhagia due to its high effectiveness in reducing menstrual blood loss while improving quality of life. 1

Initial Assessment and Medical Management

First-Line Treatments

• LNG-IUD provides localized progestin delivery, significantly reducing menstrual blood flow while offering contraceptive benefits 2, 1
• Tranexamic acid, a non-hormonal antifibrinolytic agent, effectively reduces menstrual bleeding and can be used during days of bleeding only 2, 1
• Combined oral contraceptives effectively regulate menstrual cycles and reduce bleeding through endometrial suppression 2, 1

Second-Line Medical Treatments

• NSAIDs (such as mefenamic acid) for short-term treatment (5-7 days) during bleeding episodes, which work by reducing prostaglandin levels 2
• Oral progestins can be used cyclically or continuously, particularly beneficial in women with contraindications to estrogen 1, 3
• GnRH agonists (e.g., leuprolide acetate) and antagonists (e.g., elagolix, relugolix) effectively reduce bleeding and fibroid volume, but should be used short-term due to hypoestrogenic side effects 2

Treatment Algorithm Based on Patient Factors

For Women Desiring Contraception

1. LNG-IUD (first choice) - provides both contraception and significant reduction in menstrual blood loss 2, 1
2. Combined oral contraceptives - regulate cycles and reduce bleeding 2, 1
3. Injectable contraceptives (DMPA) - may lead to amenorrhea with continued use, though initial irregular bleeding is common 2

For Women Not Desiring Contraception

1. Tranexamic acid during menstruation - reduces bleeding without affecting fertility 2, 4
2. NSAIDs during menstruation - particularly helpful if menorrhagia is accompanied by dysmenorrhea 2, 5
3. Cyclic oral progestins - can regulate menstrual cycles 3

Surgical Options (When Medical Management Fails)

• Endometrial ablation - high satisfaction rates (>95%) for women who have completed childbearing 2
• Hysteroscopic myomectomy - treatment of choice for submucous pedunculated fibroids <5cm if fibroids are the cause 2
• Uterine artery embolization (UAE) - minimally invasive alternative with high clinical success rates, though 20-25% symptom recurrence at 5-7 years 2
• Hysterectomy - definitive treatment with high satisfaction rates (90% at 2 years) but should be considered last resort due to invasiveness 2, 6

Management of Bleeding Irregularities with Contraceptive Methods

For Copper IUD Users with Heavy/Prolonged Bleeding

• NSAIDs for short-term treatment (5-7 days) during bleeding 2
• If bleeding persists and is unacceptable, consider alternative contraceptive methods 2

For Hormonal Contraceptive Users with Irregular Bleeding

• Rule out underlying gynecological problems (STDs, pregnancy, fibroids, polyps) 2
• For implant or DMPA users with heavy bleeding, consider:
  • NSAIDs for short-term treatment (5-7 days) 2
  • Low-dose COCs or estrogen for short-term treatment (10-20 days) if medically eligible 2

Special Considerations

• For women with thrombocytopenia, progestogens may be useful but should not be used longer than 6 months due to risk of meningiomas 1
• DMPA may cause initial irregular bleeding before amenorrhea develops with continued use 2
• Women using medroxyprogesterone should be monitored for fluid retention, particularly with conditions like epilepsy, migraine, asthma, or cardiac/renal dysfunction 7
• When using GnRH agonists/antagonists, consider add-back therapy (low-dose estrogen/progestin) to mitigate hypoestrogenic side effects 2

Common Pitfalls to Avoid

• Failing to rule out underlying pathology (fibroids, polyps, endometrial cancer) before initiating treatment 2, 4
• Using ergometrine for menorrhagia treatment, which has no established benefit 5
• Prolonged use of GnRH agonists without add-back therapy, leading to bone mineral density loss 2
• Inadequate counseling about expected bleeding patterns with hormonal methods, which can lead to unnecessary discontinuation 2