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 high effectiveness in reducing heavy menstrual bleeding and improving quality of life. 1

Initial Assessment

• Rule out underlying 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 bleeding pattern is heavy/prolonged or follows a regular/irregular pattern 2
• Evaluate for anemia with hemoglobin or hematocrit testing 3

Medical Treatment Options

First-Line Treatments

• Levonorgestrel-releasing intrauterine device (LNG-IUD)

  • Most effective medical treatment for menorrhagia 1
  • Reduces bleeding and leads to amenorrhea or oligomenorrhea in approximately 50% of users by 2 years 4
  • Provides contraception while treating menorrhagia 5

• Tranexamic acid (antifibrinolytic)

  • Non-hormonal option that reduces menstrual blood loss by approximately 50% 1, 5
  • Take only during menstruation 6
  • Particularly useful when contraception is not desired 6

• NSAIDs (mefenamic acid, ibuprofen, celecoxib)

  • Recommended for 5-7 days during bleeding episodes 2
  • Reduce prostaglandin levels in the endometrium 2
  • Provide additional benefit of reducing dysmenorrhea 6
  • Achieve 25-35% reduction in blood loss, with greater reduction in women with more excessive bleeding 7

Other Medical Options

• Combined oral contraceptives

  • Effective for regulating cycles and reducing bleeding 1
  • Good option when contraception is also desired 6

• Oral progestogens

  • Useful for women with anovulatory bleeding 7
  • Particularly beneficial in women with severe thrombocytopenia 1
  • Limited effectiveness (only 20% reduction) in ovulatory women with menorrhagia 7
  • Should not be used for more than 6 months to prevent meningioma risk 1

• Gonadotropin-releasing hormone (GnRH) agonists

  • Can be considered for temporary management 4
  • Limited long-term use due to hypo-estrogenic side effects 7
  • May be used in acute myeloid leukemia patients to avoid menorrhagia 4

Surgical Treatment Options

• Endometrial ablation

  • High satisfaction rates (>95%) for women who don't desire future pregnancy 1
  • Less invasive than hysterectomy 8

• Hysteroscopic myomectomy

  • Treatment of choice for pedunculated submucous fibroids <5cm 1
  • Shorter hospitalization and faster recovery than abdominal procedures 1

• Uterine artery embolization (UAE)

  • Alternative to surgery with high clinical success 1
  • 20-25% recurrence of symptoms at 5-7 years 1

• Hysterectomy

  • Definitive treatment with high satisfaction (90% at 2 years) 1
  • Consider as last resort due to invasive nature and loss of fertility 1, 8

Treatment Algorithm

1. Start with medical management:

   • For women desiring contraception: LNG-IUD or combined oral contraceptives 1, 6
   • For women not desiring contraception: Tranexamic acid or NSAIDs during menstruation 2, 6

2. If initial treatment fails after 3-6 months:

   • Try alternative medical therapy or
   • Consider surgical options based on desire for future fertility 8

3. For women with completed childbearing:

   • Consider endometrial ablation if medical management fails 1
   • Reserve hysterectomy for cases refractory to other treatments 1

Special Considerations

• In women with severe thrombocytopenia, progestin-only contraceptives may be useful, but use DMPA with caution due to its irreversibility for 11-13 weeks 2
• For women with acute myeloid leukemia, GnRH agonists can be used to prevent menorrhagia 4
• Ergometrine has no place in the treatment of menorrhagia 6