What is the first line of treatment for menorrhagia?

First-Line Treatment for Menorrhagia

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for menorrhagia, reducing menstrual blood loss more than any other medical therapy and achieving amenorrhea or oligomenorrhea in approximately 50% of users after 2 years. 1

Primary Treatment Options

Levonorgestrel Intrauterine System (First Choice)

• The LNG-IUS demonstrates superior efficacy compared to all other medical treatments, with effectiveness comparable to endometrial ablation or hysterectomy 1, 2
• Approximately 50% of users develop amenorrhea or oligomenorrhea after 2 years of use 1
• This should be the initial treatment unless contraindicated or patient preference dictates otherwise 2

Alternative First-Line Medical Therapies

When LNG-IUS is not suitable or desired, the following options are equally appropriate as first-line therapy:

Tranexamic Acid (Antifibrinolytic Agent)

• Reduces menstrual blood loss by 34-59% over 2-3 cycles 3
• Non-hormonal option, making it ideal for women who cannot or prefer not to use hormonal therapy 4, 5
• Typical dosing: 1-1.5g three times daily for 4-5 days during menstruation 3, 2
• Well-tolerated with primarily gastrointestinal side effects (12% incidence) 3
• Particularly effective in women with bleeding disorders or coagulopathies 6

NSAIDs (Mefenamic Acid or Other NSAIDs)

• Reduce menstrual blood loss by 20-60% 2
• Work by decreasing prostaglandin levels in the endometrium 7
• Less effective than tranexamic acid in head-to-head comparisons 3

Combined Oral Contraceptive Pills

• Effective for regularizing cycles and reducing bleeding 4, 1
• Suitable alternative when contraception is also desired 2
• Important caveat: Concomitant use with tranexamic acid increases thromboembolic risk and should be avoided 5

Treatment Algorithm

1. Start with LNG-IUS unless contraindicated or patient declines hormonal therapy 1, 2

2. If LNG-IUS is not suitable, choose based on patient factors:

   • Tranexamic acid: For women preferring non-hormonal therapy or with bleeding disorders 4, 3, 6
   • NSAIDs: For women with dysmenorrhea as a prominent symptom 2
   • Combined oral contraceptives: For women desiring contraception 1, 2

3. Evaluate treatment response at 3-6 months before considering surgical options 1

Critical Caveats

Avoid Combination Therapy Risks

• Never combine tranexamic acid with hormonal contraceptives due to increased thromboembolic risk 5
• Use effective non-hormonal contraception if tranexamic acid is chosen 5

Special Populations

• In women with severe thrombocytopenia, progestins may be useful but avoid DMPA due to irregular bleeding and 11-13 week irreversibility 4
• Progestins should not be used for more than 6 months due to meningioma risk 8
• Cyclic progestogens (luteal phase only) are not effective for reducing menstrual bleeding in ovulatory women 2

Ineffective Therapies to Avoid

• Luteal phase-only progestogens do not significantly reduce menstrual blood loss 3, 2
• These are less effective than tranexamic acid, NSAIDs, or combined oral contraceptives 3

Concurrent Management

Iron Supplementation

• Evaluate for iron deficiency anemia, present in 20-25% of women with menorrhagia 1
• Supplement with ferrous sulfate 200mg three times daily 1
• Continue for 3 months after anemia correction to replenish iron stores 1
• Monitor hemoglobin and MCV every 3 months for 1 year, then annually 1

Diagnostic Evaluation

• Search for underlying uterine pathology (fibroids, polyps, adenomyosis) using ultrasound 1
• Exclude coagulation disorders, particularly in women with severe bleeding 1