Treatment Options for Menorrhagia
NSAIDs, specifically mefenamic acid or ibuprofen, should be the first-line medical treatment for menorrhagia, taken for 5-7 days during menstrual bleeding, as they reduce blood loss by 25-35% and are recommended by the American College of Obstetricians and Gynecologists. 1
Initial Assessment Requirements
Before initiating treatment, rule out the following underlying conditions:
- Pregnancy (perform pregnancy test) 1, 2
- Thyroid disorders (check TSH level) 1, 3
- Sexually transmitted infections 1, 2
- Pathologic uterine conditions including fibroids and polyps (fibroids are found in 10% of women with menorrhagia overall, and 40% with severe menorrhagia) 1, 4
- Medication interactions, particularly psychotropic medications that cross the blood-brain barrier 1, 3
- Hematocrit or hemoglobin to detect anemia (present in two-thirds of women with objective menorrhagia) 3, 4
Medical Treatment Algorithm
First-Line: NSAIDs
Specific NSAID regimens:
- Ibuprofen 400 mg every 4-6 hours during bleeding episodes 5
- Mefenamic acid (dosing per standard protocols) for 5-7 day treatment courses 2, 6
- Naproxen 440-550 mg every 12 hours as an alternative 2
NSAIDs work by reducing prostaglandin levels in the endometrium and achieve a 25-35% reduction in menstrual blood loss, with proportionally greater reductions in women with more excessive bleeding 3, 7. Treatment should be short-term (5-7 days) during days of bleeding only 1, 2.
Second-Line: Antifibrinolytic Agents
Tranexamic acid reduces menstrual blood loss by approximately 50% and is particularly useful when estrogens are contraindicated 6, 7, 8. This represents a more substantial reduction than NSAIDs and should be considered when first-line therapy fails.
Third-Line: Hormonal Therapies
When NSAIDs prove inadequate (approximately 18% of women are unresponsive to NSAIDs 2), consider:
- Intrauterine levonorgestrel (LNG-IUD) - the most effective medical therapy overall 8
- Combined oral contraceptives for women requiring contraception 2, 7
- Oral progestogens - though data show only 20% reduction in blood loss in ovulatory women, questioning their use as first-line treatment 7, 8
Special Considerations for Perimenopausal Women
For climacteric menorrhagia specifically, the treatment hierarchy remains NSAIDs as first-line 1. For women with severe thrombocytopenia, progestin-only contraceptives may be useful, but DMPA should be used cautiously due to its irreversibility for 11-13 weeks 1.
Surgical Options
When medical management fails or is unacceptable:
- Endometrial ablation/destruction - increasingly used as an alternative to hysterectomy over the past decade 6, 4
- Hysterectomy - treatment of last resort, though it accounts for two-thirds of all hysterectomies performed 6, 3
- Fibroid embolization - newer option for fibroid-related menorrhagia 6
Notably, approximately 50% of women undergoing hysterectomy for menorrhagia have no pathology found, and half have a normal uterus, suggesting that medical management should be exhausted first 6, 4.
Critical Pitfalls to Avoid
- Failing to rule out underlying pathology before initiating treatment leads to ineffective or delayed treatment 1
- Inadequate patient counseling about expected bleeding pattern changes with hormonal treatments results in non-adherence 1
- Prescribing progestogens as first-line in ovulatory women, as they achieve only 20% reduction in blood loss compared to 25-50% with other agents 7
- Using doses of ibuprofen greater than 400 mg for menorrhagia, as controlled trials show no additional benefit beyond 400 mg 5
Follow-Up Protocol
- Monitor hemoglobin and MCV at three-month intervals for one year, then annually 9
- Iron supplementation (ferrous sulfate 200 mg three times daily) should continue for three months after correction of anemia to replenish stores 9
- If bleeding irregularities persist despite treatment and remain unacceptable to the patient, consider alternative contraceptive methods or surgical options 1, 2