What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

The levonorgestrel intrauterine system (LNG-IUS) is the first-line treatment for menorrhagia, demonstrating effectiveness comparable to endometrial ablation or hysterectomy while preserving fertility. 1

Initial Medical Management

First-Line Pharmacological Options

Hormonal Therapy:

• LNG-IUS (Mirena) is the most effective medical treatment, reducing menstrual blood loss by 71-96% and should be offered first unless contraindicated 1, 2
• Combined oral contraceptives effectively regulate cycles and reduce bleeding, particularly useful when contraception is also desired 1, 3

Non-Hormonal Therapy (when contraception not needed):

• Tranexamic acid is the most effective non-hormonal option, reducing menstrual blood loss by 40-60% through antifibrinolytic action 1, 4, 2, 5
• NSAIDs (mefenamic acid 500mg three times daily or ibuprofen 600-800mg every 6-8 hours) reduce blood loss by 20-30% and provide additional benefit for dysmenorrhea 6, 7, 4, 2
  • Treatment should be taken with food during days of bleeding only (5-7 days) 8, 6
  • Mefenamic acid is specifically effective for 5-day treatment courses 6

Treatment Selection Algorithm

If contraception desired:

1. LNG-IUS as first choice 1, 3
2. Combined oral contraceptives as alternative 1, 3
3. Oral progestogens (continuous dosing) 3

If contraception NOT desired:

1. Tranexamic acid (most effective reduction in blood loss) 2, 5
2. NSAIDs (lowest side effect profile, added dysmenorrhea benefit) 4, 3, 2
3. LNG-IUS (if long-term solution preferred) 1

Important Diagnostic Considerations Before Treatment

Rule out underlying pathology:

• Structural abnormalities: fibroids, polyps, or other uterine pathology (present in ~50% of cases) 6, 4, 2
• Pregnancy complications 6, 9
• Sexually transmitted infections 8, 6
• Endocrine disorders: thyroid dysfunction, polycystic ovary disease 9
• Bleeding disorders and coagulopathies 9
• Medications (especially psychotropics) 9

Essential initial testing:

• Hemoglobin/hematocrit to assess anemia 9
• TSH to evaluate thyroid function 9
• Pregnancy test 6, 9
• Pelvic examination with vaginal sonography if bleeding pattern changed or anemia present 2

Surgical Options (When Medical Management Fails)

Minimally Invasive Procedures:

• Endometrial ablation for women not desiring future pregnancy, with >95% patient satisfaction 1, 4
• Hysteroscopic myomectomy for submucous pedunculated fibroids <5cm, offering shorter hospitalization and faster recovery 1
• Uterine artery embolization (UAE) as alternative to surgery with high success rates, though 20-25% symptom recurrence at 5-7 years 1

Definitive Treatment:

• Hysterectomy provides definitive cure with 90% satisfaction at 2 years but should be reserved as last resort due to invasiveness and fertility loss 1, 4

Special Populations

Women of reproductive age on anticoagulation:

• Increased risk of abnormal uterine bleeding (9-14% baseline prevalence, higher with anticoagulants) 8
• Rivaroxaban specifically associated with prolonged menstrual bleeding (>8 days in 27% vs 8.3% with warfarin) and increased need for intervention 8
• Counsel about bleeding risk and monitor carefully during first cycles after anticoagulation initiation 8

Women with severe thrombocytopenia:

• Oral progestogens may be useful 1
• Avoid DMPA due to irregular bleeding and 11-13 week irreversibility 1
• Do not use progestogens >6 months due to meningioma risk 1

Common Pitfalls to Avoid

Ineffective treatments:

• Cyclic progestogens (norethisterone) do NOT significantly reduce bleeding in ovulating women despite being frequently prescribed 2, 5
• Ergometrine has no place in menorrhagia treatment 3

Treatment failure recognition:

• If medical therapy fails after adequate trial (typically 3-6 months), proceed to surgical evaluation rather than continuing ineffective medications 1, 2
• Approximately 18% of women are unresponsive to NSAIDs 6

Counseling requirements:

• Women using LNG-IUS should expect irregular spotting for 3-6 months before bleeding decreases; approximately 50% develop amenorrhea by 2 years 8
• Enhanced counseling about expected bleeding patterns reduces treatment discontinuation 8