What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the first-line treatment for menorrhagia, demonstrating high effectiveness in reducing heavy menstrual bleeding and improving quality of life. 1

Initial Assessment and Diagnosis

• Rule out underlying health conditions that may cause heavy bleeding, including medication interactions, sexually transmitted infections, pregnancy, thyroid disorders, and pathologic uterine conditions (polyps or fibroids) 2
• Determine if the bleeding pattern is heavy/prolonged, and if it follows a regular or irregular pattern 2
• Perform a pelvic examination and vaginal sonography, especially if the menstrual pattern has changed substantially or if anemia is present 3
• Consider sonohysterography or hysteroscopy for more reliable diagnosis of endometrial polyps and fibroids 3

First-Line Medical Treatments

• Levonorgestrel-releasing intrauterine system (LNG-IUD) is highly effective for reducing menstrual blood loss, with effectiveness comparable to endometrial ablation or hysterectomy 1, 4
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days during bleeding episodes reduce menstrual blood loss by 20-60% 2, 5
  • Options include ibuprofen, mefenamic acid, or celecoxib, which reduce prostaglandin levels in the endometrium 2
• Tranexamic acid, an antifibrinolytic agent, effectively reduces menstrual blood loss but may be expensive 1, 4
• Combined oral contraceptives help regulate menstrual cycles and reduce bleeding 1, 4

Second-Line Medical Treatments

• Oral progestogens are useful especially in women with severe thrombocytopenia 1
  • Note: Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 3
  • Progestogens should not be used for more than 6 months to prevent meningioma development 1
• Medroxyprogesterone acetate can transform proliferative endometrium into secretory endometrium when administered to women with adequate endogenous estrogen 6
  • However, it is not recommended for secondary amenorrhea or dysfunctional uterine bleeding due to its prolonged action 6

Surgical Options (When Medical Management Fails)

• Endometrial ablation is an option for women who don't desire future pregnancy, with high satisfaction rates (>95%) 1
• Hysteroscopic myomectomy is the treatment of choice for submucous pedunculated fibroids <5 cm 1
• Uterine artery embolization (UAE) is an alternative to surgery with high clinical success, though 20-25% experience symptom recurrence at 5-7 years 1
• Hysterectomy is the most definitive treatment with high satisfaction (90% at 2 years) but should be considered as a last option due to its invasive nature and loss of fertility 1, 4

Treatment Algorithm

1. Start with medical therapy before considering surgical interventions 3
2. For women desiring contraception: LNG-IUD or combined oral contraceptives 7
3. For women not desiring contraception: Tranexamic acid or NSAIDs during menstruation 7
4. If initial medical therapy fails, consider alternative medical options or surgical interventions 4
5. Women with hyperplasia with atypia or adenocarcinoma should be referred to a gynecologist or gynecologic oncologist 4

Common Pitfalls to Avoid

• Failing to rule out underlying pathology before initiating treatment can lead to ineffective or delayed treatment 2
• Not providing adequate counseling about expected changes in bleeding patterns with hormonal treatments can lead to patient non-adherence 2
• Using DMPA without caution due to its irreversibility for 11-13 weeks after administration and potential for irregular bleeding initially 2, 1