What are the treatment options for heavy menstrual bleeding during perimenopause?

From the Guidelines

To treat perimenopause heavy bleeding, the most effective option is often hormonal treatments, including combined hormonal contraceptives or the levonorgestrel intrauterine system (Mirena), which can reduce bleeding by up to 90% within 3-6 months 1.

Treatment Options

The following treatment options are available for heavy menstrual bleeding during perimenopause:

• Hormonal treatments: combined hormonal contraceptives (pills, patches, or rings) or progestin-only contraception, such as progestin-only pills or the levonorgestrel intrauterine system (Mirena) 1
• Non-hormonal medications: tranexamic acid (Lysteda) or nonsteroidal anti-inflammatory drugs like ibuprofen 2, 3, 4
• Surgical options: endometrial ablation or hysterectomy, which may be considered if medical treatment fails or is contraindicated 1

Considerations

When considering treatment options, it is essential to:

• Evaluate for underlying conditions, such as uterine fibroids or polyps, and treat or refer for care if necessary 2, 3, 4
• Consider the patient's medical eligibility for hormonal treatments and potential interactions with other medications 2, 3, 4
• Counsel patients on alternative methods and offer another method if desired, especially if bleeding persists or is unacceptable 2, 3, 4

Lifestyle Measures

Lifestyle measures can complement medical treatments and help prevent anemia from blood loss, including:

• Maintaining a healthy weight
• Managing stress
• Ensuring adequate iron intake

From the FDA Drug Label

Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease

The treatment options for heavy menstrual bleeding during perimenopause may include:

• Hormonal management: Changing to an oral contraceptive with a higher estrogen content may help minimize menstrual irregularity, but this should be done with caution due to the increased risk of thromboembolic disease.
• Diagnostic evaluation: Ruling out pregnancy or malignancy is essential in cases of undiagnosed persistent or recurrent abnormal bleeding.
• Alternative preparations: Switching to a different oral contraceptive preparation may help solve the problem of heavy menstrual bleeding. 5

From the Research

Treatment Options for Heavy Menstrual Bleeding during Perimenopause

• Medical therapies suitable for perimenopausal women with heavy menstrual bleeding include intrauterine levonorgestrel, oral progestogens, the combined oral contraceptive pill, tranexamic acid, mefenamic acid, danazol, and gonadotrophin-releasing hormone (GnRH) analogues 6
• The levonorgestrel intrauterine system (LNG-IUS) is a highly effective option for preventing pregnancy and treating menstrual disturbances, and can be combined with estrogen therapy for a smooth transition to menopause 7
• Combined oral contraceptives (COCs) can also be used to treat heavy menstrual bleeding and prevent climacteric symptoms, and have a protective effect against ovarian and endometrial cancers 8
• Progestogen-only contraceptives, such as pills, depot injectables, and implants, are alternative options for women who cannot use COCs 8
• The levonorgestrel-releasing intrauterine system is a highly effective treatment for heavy menstrual bleeding, and is endorsed as a first-line treatment in several international guidelines 9

Hormonal Therapies for Heavy Menstrual Bleeding

• Hormonal treatment is a first-line evidence-based management strategy for abnormal uterine bleeding, including heavy menstrual bleeding 9
• Commonly used hormonal treatments include combined hormonal contraceptives, progestin-only preparations, and intrauterine release of levonorgestrel through the levonorgestrel-releasing intrauterine system 9
• These treatments have been shown to be effective in reducing menstrual blood loss and improving quality of life for women with heavy menstrual bleeding 6, 9