What are the treatment options for a 36-year-old female with menorrhagia (heavy irregular periods)?

Treatment Options for Heavy Irregular Periods in a 36-Year-Old Woman

First-line medical treatment should be either a levonorgestrel-releasing intrauterine device (LNG-IUD) or combined hormonal contraceptives, as these are the most effective options recommended by ACOG for managing abnormal uterine bleeding associated with ovulatory dysfunction. 1

Initial Evaluation Required

Before initiating any treatment, you must rule out underlying pathology:

• Pregnancy testing is mandatory 2
• Assess for structural causes including polyps, fibroids, adenomyosis, and endometrial pathology 1
• Check thyroid function and prolactin levels to exclude endocrine causes 1
• Consider endometrial biopsy if she has risk factors for endometrial cancer (though at age 36, this is primarily indicated if she has recurrent anovulation or other risk factors) 3
• Transvaginal ultrasound is the first-line imaging modality to evaluate for structural abnormalities 1, 4

Medical Treatment Options (Ranked by Effectiveness)

Most Effective: Levonorgestrel-Releasing IUD (LNG-IUD)

• The LNG-IUD reduces menstrual blood loss by 71-95%, making it the most effective long-term medical treatment 5
• Over time, many women experience only light bleeding or amenorrhea 5
• Effectiveness is comparable to endometrial ablation or hysterectomy 6
• This should be your first choice if she desires contraception or is open to an IUD 3, 4

Highly Effective: Combined Hormonal Contraceptives (CHCs)

• ACOG specifically recommends combined hormonal contraceptives (pills, patch, or ring) as first-line treatment for abnormal uterine bleeding with ovulatory dysfunction 1
• These regulate menstrual cycles and reduce bleeding 1
• Can be used continuously or cyclically depending on patient preference 1

Alternative Medical Options

Tranexamic Acid:

• Reduces menstrual blood loss by approximately 80 mL/cycle (about 50% reduction) 2
• Particularly useful when hormonal contraception is contraindicated or pregnancy is desired soon 4
• Critical contraindication: Do not use if she has any history of thrombosis or thromboembolic disease 2
• More expensive than other options 3

NSAIDs (Mefenamic Acid or Ibuprofen):

• Reduce menstrual blood loss by 20-50% 6, 4
• Use for 5-7 days during menstruation 1, 5
• Less effective than LNG-IUD or tranexamic acid but useful as adjunctive therapy 5
• Avoid in women with cardiovascular disease due to MI risk 5

Progestin-Only Contraception:

• Oral progestins for 21 days per month can regulate cycles 1, 3
• Less effective than LNG-IUD but an option if other methods are contraindicated 4

Surgical Options (Second-Line)

If medical treatment fails, is contraindicated, or not tolerated after adequate trial:

Endometrial Ablation:

• Effective for reducing bleeding when medical management fails 1, 2
• Less effective if fibroids or adenomyosis are present 2
• Preserves the uterus but future pregnancy is contraindicated 4

Hysterectomy:

• Most definitive treatment with complete resolution of bleeding 2, 3
• Reserved for failed medical/conservative surgical management 1, 4
• Should be performed vaginally or laparoscopically rather than abdominally 4

Practical Algorithm

1. Rule out pregnancy, structural pathology, and endocrine causes with exam, ultrasound, and labs 1, 2

2. Start with LNG-IUD if she's open to it - highest efficacy for long-term management 5, 4

3. If she prefers oral medication or needs immediate treatment, use combined hormonal contraceptives 1

4. If hormones are contraindicated, use tranexamic acid (if no thrombosis risk) 2, 4

5. Add NSAIDs during menses for additional symptom relief 5, 6

6. If medical treatment fails after 3-6 months, consider endometrial ablation 1, 4

7. Reserve hysterectomy for failed conservative management 1, 4

Critical Pitfalls to Avoid

• Do not use cyclic progestins alone in ovulating women - they are ineffective for reducing menstrual blood loss 6
• Avoid aspirin - it may increase bleeding 5
• Screen for von Willebrand disease if she has had heavy periods since menarche, as coagulation disorders are commonly missed 3
• Do not skip endometrial assessment if she has risk factors for endometrial cancer or if bleeding persists despite treatment 1, 3