What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the first-line treatment for menorrhagia, demonstrating superior effectiveness in reducing menstrual blood loss and improving quality of life. 1

First-Line Medical Treatments

• LNG-IUD reduces menstrual blood loss significantly and has high patient satisfaction rates, making it the preferred initial treatment for women with menorrhagia 1
• Tranexamic acid (1.5-4g daily during menstruation) is an effective non-hormonal option that reduces menstrual blood loss by 34-59% by preventing fibrin degradation 2, 3
• NSAIDs (ibuprofen, mefenamic acid) taken for 5-7 days during bleeding episodes reduce prostaglandin levels in the endometrium and decrease blood loss by approximately 20% 4, 3
• Combined oral contraceptives effectively regulate cycles and reduce bleeding, particularly useful for women who also desire contraception 1
• Oral progestins can be used, especially in women with contraindications to other treatments, though they're less effective than other options in women who ovulate normally 1, 5

Surgical and Interventional Options

• Endometrial ablation has high satisfaction rates (>95%) and is appropriate for women who have completed childbearing 1
• Hysteroscopic myomectomy is the preferred treatment for submucosal fibroids <5cm that are contributing to menorrhagia 1
• Uterine artery embolization (UAE) is an effective alternative to surgery with high clinical success, though 20-25% of patients experience symptom recurrence within 5-7 years 1
• Hysterectomy is the definitive treatment with 90% satisfaction at 2 years but should be considered only after other treatments have failed due to its invasive nature and irreversible effect on fertility 1

Treatment Algorithm

1. Initial evaluation: Rule out underlying conditions (fibroids, polyps, coagulopathies, thyroid disorders) 4
2. First-line treatment:
   • LNG-IUD for women not desiring immediate pregnancy 1
   • Tranexamic acid (1-1.5g four times daily for first 5 days of cycle) for women desiring pregnancy or with contraindications to hormonal methods 2, 3
   • NSAIDs as an alternative non-hormonal option 4
3. Second-line treatment:
   • Combined oral contraceptives or cyclic progestins 1
   • Consider combination therapy with tranexamic acid and NSAIDs for enhanced effect 5
4. Treatment failure:
   • Endometrial ablation or hysteroscopic procedures for anatomical causes 1
   • Uterine artery embolization for fibroids 1
   • Hysterectomy as definitive treatment 1

Special Considerations

• For women with severe thrombocytopenia, progestin-only methods may be safer, but medroxyprogesterone acetate (DMPA) should be used cautiously due to its irreversibility for 11-13 weeks 1, 4
• Higher doses of tranexamic acid (up to 3g daily in divided doses) may be needed for menorrhagia associated with bleeding disorders like von Willebrand disease 6
• Progestins should not be used for more than 6 months continuously due to potential risk of meningiomas 1
• Iron supplementation should be considered in women with iron deficiency anemia resulting from menorrhagia 7

Common Pitfalls to Avoid

• Failing to rule out underlying pathology before initiating treatment can lead to ineffective management 4
• Not providing adequate counseling about expected changes in bleeding patterns with hormonal treatments can lead to poor adherence 4
• Overlooking the impact of menorrhagia on quality of life and iron status 7
• Using cyclic progestins as first-line therapy in ovulating women, as they have limited effectiveness in this population 5