How to manage menorrhagia (heavy menstrual bleeding)?

Management of Heavy Menstrual Bleeding

For heavy menstrual bleeding, first-line treatment should be nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days during bleeding episodes, followed by hormonal options like levonorgestrel IUD if bleeding persists. 1

Initial Assessment and Management

• Rule out underlying gynecological problems before treatment, including pregnancy, sexually transmitted infections, or pathologic uterine conditions (e.g., polyps or fibroids) 1, 2
• Heavy menstrual bleeding (menorrhagia) is objectively defined as blood loss ≥80 ml per menstruation, affecting approximately 30% of women 3
• First-line treatment for acute heavy bleeding is NSAIDs for 5-7 days during days of bleeding 1

First-Line Treatment Options

Non-Hormonal Options:

• NSAIDs (5-7 days during bleeding) have been shown to significantly reduce menstrual blood loss in multiple studies 1
• Tranexamic acid is an effective non-hormonal alternative that can significantly reduce mean blood loss during treatment compared with placebo 1
• Caution: Tranexamic acid is contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

Hormonal Options:

• Levonorgestrel-releasing intrauterine device (LNG-IUD) is highly effective for heavy menstrual bleeding with effectiveness comparable to endometrial ablation or hysterectomy 2, 4
• Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol are recommended as initial therapy for patients without cardiovascular risk factors 5, 2
• Extended or continuous cycle regimens of COCs may be beneficial for severe menstrual bleeding to minimize blood loss 5, 2

Management Algorithm

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

2. If bleeding persists and is unacceptable:

   • For women desiring contraception: Consider LNG-IUD or combined hormonal contraceptives 1, 5
   • For women with cardiovascular risk factors: LNG-IUD is preferred over COCs 2
   • For women with no contraindications to estrogen: COCs with 30-35 μg ethinyl estradiol 5, 2

3. For persistent bleeding despite initial treatment:

   • Consider tranexamic acid if not contraindicated 1
   • For Cu-IUD users with heavy bleeding: NSAIDs for 5-7 days; if bleeding persists, consider alternative contraceptive methods 1

Special Considerations

• COCs increase the risk of venous thromboembolism (VTE) three to fourfold (up to 4 per 10,000 woman-years) 5, 2
• Unscheduled spotting or light bleeding is common during the first 3-6 months of hormonal contraceptive use and generally decreases with continued use 1
• If bleeding persists despite medical management and significantly impacts quality of life, consider referral for surgical options 4
• For women with fibroids causing heavy bleeding, medical management includes NSAIDs and hormonal options before considering surgical interventions 1

Treatment Efficacy

• NSAIDs reduce menstrual blood loss by 20-60% 4
• LNG-IUD effectiveness is comparable to endometrial ablation or hysterectomy for reducing heavy bleeding 4
• Tranexamic acid can significantly reduce mean blood loss during treatment compared with placebo 1
• Combined hormonal contraceptives provide both contraception and therapeutic benefits for heavy bleeding 5, 2

Drug treatment should be thoroughly evaluated before surgical interventions are considered, as effective medical management can significantly improve quality of life and avoid unnecessary procedures 4.