What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

The levonorgestrel intrauterine device (LNG-IUD) is the first-line treatment for menorrhagia, demonstrating superior efficacy in reducing menstrual blood loss and improving quality of life. 1

Initial Assessment

Before initiating treatment, rule out underlying pathology that may cause heavy bleeding 2:

• Structural abnormalities: polyps, fibroids, adenomyosis (found in 10-40% of menorrhagia cases depending on severity) 3
• Systemic conditions: thyroid disorders, liver/kidney dysfunction, bleeding disorders 4
• Medications: psychotropics, anticoagulants 4
• Pregnancy-related: incomplete abortion, ectopic pregnancy 4
• Malignancy: endometrial cancer (Pap test recommended) 4

Medical Treatment Algorithm

First-Line Options

For women desiring contraception:

• LNG-IUD: Most effective option, reduces bleeding by approximately 50% and leads to amenorrhea in 50% of users by 2 years 5, 1
  • Counsel patients about expected spotting during first 3-6 months 5
  • Heavy bleeding is uncommon after initial adjustment period 5

For women NOT desiring contraception:

• NSAIDs (mefenamic acid, ibuprofen): First-line per ACOG guidelines, used for 5-7 days during menses 2

  • Reduce blood loss by 25-35%, with greater reduction in women with more severe bleeding 6, 7
  • Additional benefit of reducing dysmenorrhea 8
  • Lowest incidence of side effects among medical options 8

• Tranexamic acid (antifibrinolytic): Highly effective non-hormonal option 1

  • Reduces menstrual blood loss by approximately 50% 6, 7
  • Particularly useful when estrogens are contraindicated 7
  • Should be used only during menstruation 8

Second-Line Medical Options

• Combined oral contraceptives: Effective for regulating cycles and reducing bleeding 1, 8

  • Appropriate when contraception is desired 8
  • Evidence for low-dose formulations requires further study 7

• Oral progestogens: Useful in specific populations 1

  • Effective in anovulatory women 7
  • Only 20% reduction in ovulatory women, questioning their use as first-line 7
  • Particularly useful in women with severe thrombocytopenia 5, 1
  • Caution: Do not use for more than 6 months due to meningioma risk 1
  • Avoid DMPA in acute settings due to irreversibility for 11-13 weeks and initial irregular bleeding 5, 1

Third-Line Medical Options (Short-term use)

• GnRH analogues: Highly effective, inducing amenorrhea 7

  • Long-term use contraindicated due to hypoestrogenic effects 7
  • Reserved for preoperative endometrial thinning or temporary management 3

• Danazol: Effective but significant side effects limit use 3, 7

Surgical Treatment Options

When medical management fails or is contraindicated:

Minimally Invasive Procedures

• Endometrial ablation: For women with completed childbearing 1

  • 95% patient satisfaction 1

  • Multiple techniques available: laser, electrodiathermy, "roller ball" 4
  • Less invasive than hysterectomy with shorter recovery 1

• Hysteroscopic myomectomy: For submucous pedunculated fibroids <5 cm 1

  • Shorter hospitalization and faster recovery than open surgery 1

• Uterine artery embolization (UAE): Alternative to surgery 1

  • High initial success and patient satisfaction 1
  • Important caveat: 20-25% symptom recurrence at 5-7 years 1

Definitive Surgical Treatment

• Hysterectomy: Last resort option 1, 4
  • 90% satisfaction at 2 years 1
  • Accounts for two-thirds of hysterectomies performed 6
  • Note: 50% of hysterectomies for menorrhagia reveal normal uterus 6, 3
  • Consider only after failed medical/conservative surgical management due to invasiveness and permanent loss of fertility 1

Special Populations

Women with severe thrombocytopenia:

• Progestin-only contraceptives may be beneficial 5, 1
• Avoid DMPA due to prolonged irreversibility 5, 1

Women on anticoagulation:

• Rivaroxaban associated with increased menorrhagia (27% vs 8.3% with warfarin) 5
• Counsel about increased bleeding risk with NOACs, especially during first cycles 5
• May require change in hormonal or anticoagulation therapy 5

Perimenopausal women:

• NSAIDs remain first-line for 5-7 days during bleeding 2
• Consider underlying anovulation as etiology 4

Critical Pitfalls to Avoid

• Failing to exclude pathology before treatment: Always assess for structural abnormalities, malignancy, and systemic causes 2
• Inadequate patient counseling: Thoroughly discuss expected bleeding patterns with hormonal treatments to prevent non-adherence 2
• Prescribing oral progestogens as first-line in ovulatory women: Only 20% reduction in blood loss, inferior to other options 7
• Using ergometrine: No place in menorrhagia treatment 8
• Prolonged progestogen use: Discontinue after 6 months due to meningioma risk 1
• Performing hysterectomy without adequate medical trial: 50% have normal uterus at pathology 6, 3