What are the treatment options for heavy menstruation?

Treatment Options for Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line medical treatment for heavy menstrual bleeding, followed by antifibrinolytics (tranexamic acid) and nonsteroidal anti-inflammatory drugs (NSAIDs). 1

First-Line Treatment Options

Evaluation Before Treatment

• Before initiating treatment, clinically evaluate for underlying gynecological problems such as uterine fibroids, polyps, adenomyosis, pregnancy, or STDs, especially in women with new onset of heavy bleeding 2
• Treatment should address both the reduction of blood loss and improvement in quality of life 1

Medical Treatments (in order of effectiveness)

1. Levonorgestrel-releasing intrauterine system (LNG-IUS)

   • Results in the largest reduction of menstrual blood loss among first-line treatments 1
   • Mean reduction of approximately 105 mL/cycle compared to baseline 1
   • Particularly effective for heavy bleeding related to endometrial dysfunction and some structural causes (fibroids and adenomyosis) 3

2. Antifibrinolytics (Tranexamic acid)

   • Probably the second most effective option for reducing menstrual blood loss 1
   • Mean reduction of approximately 80 mL/cycle 1
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2

3. Combined hormonal contraceptives

   • Effective for heavy menstrual bleeding 3
   • Available as oral pills or vaginal ring 3
   • May be used for 10-20 days to treat heavy bleeding when using other contraceptive methods 2

4. Nonsteroidal anti-inflammatory drugs (NSAIDs)

   • Short-term treatment (5-7 days) during days of bleeding 2
   • Examples include indomethacin, mefenamic acid, flufenamic acid, and diclofenac sodium 2
   • Most studies demonstrate significant reductions in menstrual blood loss 2, 4
   • For dysmenorrhea, ibuprofen 400 mg every 4 hours as needed 5
   • Less effective than tranexamic acid or danazol, but fewer side effects 4

5. Oral progestogens

   • Long-cycle progestogens (≥3 weeks per cycle) are more effective than short-course regimens 1, 3
   • Mean reduction of approximately 77 mL/cycle with long-cycle regimens 1

Second-Line Treatment Options

Surgical Interventions

• Consider when medical management fails or is unacceptable to the patient 2

1. Hysterectomy

   • Most definitive treatment for heavy menstrual bleeding 2
   • Provides complete resolution of bleeding symptoms 2
   • Associated with longer hospitalization, recovery time, and higher risk of complications compared to less invasive procedures 2
   • Minimally invasive approaches (vaginal or laparoscopic) preferred when possible 2

2. Endometrial Ablation

   • Both resectoscopic (REA) and non-resectoscopic (NREA) techniques are effective 1
   • Increases patient satisfaction and reduces bleeding 1
   • Less invasive than hysterectomy with shorter recovery time 2
   • May be less effective in women with fibroids or adenomyosis 2

3. Uterine Artery Embolization (UAE)

   • Effective for heavy bleeding associated with fibroids 2
   • Causes persistent decreases in pain and heavy bleeding 2
   • Average decrease in fibroid size >50% at 5 years 2
   • Side effects include pelvic pain and post-embolization syndrome 2

Treatment Algorithm

1. Initial assessment:

   • Rule out underlying pathology (fibroids, polyps, malignancy) 2
   • Consider patient's age, desire for future fertility, and other symptoms 1

2. First-line treatment selection:

   • For women not seeking pregnancy: LNG-IUS preferred 3
   • For women seeking pregnancy: NSAIDs or tranexamic acid during menstruation 3
   • For women with contraindications to hormonal methods: Tranexamic acid or NSAIDs 1, 3

3. If first-line treatment fails:

   • Try alternative medical therapy or combination of treatments 2
   • Consider second-line treatments including surgical options 2
   • Counsel on alternative contraceptive methods if bleeding is related to current method 2

Common Pitfalls and Considerations

• Tranexamic acid safety: FDA warning states it's contraindicated in women with active thromboembolic disease or history/risk of thrombosis 2
• NSAIDs effectiveness: While generally helpful, the reduction in blood loss may be insufficient for women with very heavy bleeding 3
• Bleeding with contraceptives: Unscheduled spotting or heavy bleeding is common during the first 3-6 months of copper IUD use and generally decreases with continued use 2
• Treatment persistence: Many women discontinue medical treatments due to side effects, lack of efficacy, or desire for more definitive treatment 3, 6
• Aspirin caution: Not recommended for heavy menstrual bleeding as it may increase blood loss in women with lower baseline menstrual blood loss 2