What are the treatment options for a patient with menorrhagia (heavy menses)?

Treatment Options for Menorrhagia (Heavy Menses)

The first-line treatment for menorrhagia includes nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days during days of bleeding, which effectively reduces menstrual blood loss by 20-60%. 1, 2

Initial Assessment

• Evaluate severity of bleeding - bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation 3
• Check for signs of hemodynamic instability (tachycardia, hypotension) which may indicate significant blood loss 3
• Rule out pregnancy in all reproductive-age women with abnormal uterine bleeding 1
• Consider underlying gynecological problems such as:
  • Uterine fibroids or polyps (most common in women over 40) 2
  • Sexually transmitted infections 4
  • Medication interactions 4
  • Thyroid disorders 4

First-Line Medical Treatment Options

• NSAIDs for 5-7 days during days of bleeding:
  • Multiple studies have demonstrated significant reductions in mean total menstrual blood loss with various NSAIDs 4, 5
  • Effective options include indomethacin, mefenamic acid, flufenamic acid, and diclofenac sodium 4
  • NSAIDs reduce heavy menstrual bleeding when compared with placebo but are less effective than tranexamic acid 5

Second-Line Medical Treatment Options

• Levonorgestrel-releasing intrauterine device (LNG-IUD):

  • Reduces menstrual blood loss by 71-95% 1, 3
  • Effectiveness comparable to endometrial ablation or hysterectomy 2
  • Also provides contraception while treating heavy bleeding 3

• Tranexamic acid:

  • Reduces menstrual blood loss by 20-60% 2
  • Non-hormonal alternative that may reduce bleeding symptoms 4
  • Contraindicated in women with active thromboembolic disease or history of thrombosis 4

• Combined hormonal contraceptives:

  • Effective option for women who also desire contraception 1
  • Can be used for 10-20 days as treatment for heavy bleeding in women using implants or injectables 4

• Cyclic oral progestin:

  • Reduces bleeding by approximately 87% 3
  • May result in irregular bleeding patterns 3
  • Note: Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 2

Treatment Algorithm

1. Start with NSAIDs for 5-7 days during days of bleeding 4

2. If bleeding persists after 1-3 cycles, consider:

   • LNG-IUD (most effective medical option) 1, 3
   • Tranexamic acid (if hormonal methods are contraindicated) 1, 2
   • Combined hormonal contraceptives 1

3. If an underlying gynecological problem is found:

   • Treat the condition or refer for care 4
   • For fibroids, consider medical management with GnRH agonists or antagonists which can reduce tumor volume 4

4. If bleeding remains unacceptable despite medical treatment:

   • Counsel on alternative contraceptive methods 4
   • Consider surgical options such as endometrial ablation or hysterectomy 2, 6

Special Considerations

• Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1
• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful can improve treatment adherence 4
• For women with copper IUDs experiencing heavy bleeding, NSAIDs for 5-7 days is the recommended treatment 4
• For women using hormonal contraceptives with bleeding issues, treatment options vary by method:
  • LNG-IUD users: NSAIDs (5-7 days) or hormonal treatment with COCs/estrogen (10-20 days) 4
  • Implant users: NSAIDs (5-7 days) or hormonal treatment with COCs/estrogen (10-20 days) 4

Common Pitfalls and Caveats

• Subjective assessment of blood loss often doesn't reflect actual blood loss - objective measures should be used when possible 2
• Failure to evaluate for underlying conditions can lead to ineffective treatment 4
• Cyclic progestogens are commonly prescribed but not effective for women who ovulate normally 2
• Tranexamic acid is effective but contraindicated in women with thromboembolic disease 4
• Drug treatment should be evaluated before surgical interventions are considered 2