What are the management options for menorrhagia?

Management of Menorrhagia

First-Line Treatment Recommendation

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for menorrhagia, reducing menstrual blood loss by up to 96% after 12 months and resulting in amenorrhea or oligomenorrhea in approximately 50% of users after 2 years. 1, 2

Treatment Algorithm by Clinical Context

When Contraception is Desired or Acceptable

• LNG-IUS is the preferred option, providing both contraceptive benefit and the greatest reduction in menstrual blood loss compared to all other medical therapies 1, 3
• Combined oral contraceptives are an effective alternative, regularizing cycles and reducing bleeding 1, 4
• Oral contraceptives reduce blood loss significantly more than NSAIDs, antifibrinolytics, or oral progestins 5, 6

When Contraception is Not Desired or Hormonal Therapy is Contraindicated

• Tranexamic acid (1.5-2g three times daily during menstruation) is the first-line non-hormonal option, reducing menstrual blood loss by 34-59% over 2-3 cycles 1, 2
• Tranexamic acid is particularly effective in women with bleeding disorders or coagulopathies 1
• This agent only requires administration during menstruation (4-7 days per cycle), improving compliance 2, 6
• NSAIDs (mefenamic acid, flurbiprofen) are less effective than tranexamic acid but reduce blood loss more than placebo and have the added benefit of reducing dysmenorrhea 2, 6

Special Population: Severe Thrombocytopenia

• Progestins (such as norethindrone) are useful in women with severe thrombocytopenia 1, 4
• Avoid depot medroxyprogesterone acetate (DMPA) due to irregular bleeding and 11-13 week irreversibility 1, 4
• Do not use progestins for more than 6 months due to risk of meningiomas 1, 4

Essential Diagnostic Evaluation

Mandatory Initial Testing

• Screen for iron deficiency anemia, as menorrhagia is the most common cause of iron deficiency in women of reproductive age, affecting 20-25% of this population 1
• Evaluate for uterine pathology (fibroids, polyps, adenomyosis) using ultrasound or saline infusion sonohysteroscopy 1, 3
• Exclude coagulation disorders, particularly in women with severe thrombocytopenia 1

When to Perform Endometrial Biopsy

• Endometrial biopsy is effective for diagnosing precancerous lesions and adenocarcinoma but not for intracavitary lesions 3
• Consider in women over 45 years or those with risk factors for endometrial hyperplasia/cancer 7

Anemia Management

• Supplement with ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1
• Add ascorbic acid to improve iron absorption if response is insufficient 1
• Continue treatment for three months after correction of anemia to replenish iron stores 1
• Monitor hemoglobin and erythrocyte indices every 3 months for 1 year, then annually 1

Surgical Options When Medical Management Fails

Minimally Invasive Procedures

• Endometrial ablation is appropriate for women who have completed childbearing, with satisfaction rates exceeding 95% 4
• Uterine artery embolization (UAE) has an 81-100% clinical success rate, with symptom improvement in 83% of women at 3 months 1, 4
• Important caveat: UAE has a 20-25% recurrence rate at 5-7 years, requiring patient counseling about potential need for additional intervention 1, 4
• Hysteroscopic myomectomy is the treatment of choice for pedunculated submucous fibroids <5cm, offering shorter hospitalization and faster recovery 4

Definitive Surgical Treatment

• Hysterectomy results in 90% satisfaction at 2 years but should be considered last resort due to invasiveness and loss of fertility 4, 3
• Both hysterectomy and endometrial ablation result in the greatest satisfaction rates when future childbearing is not desired 3

Treatment Efficacy Hierarchy

From most to least effective for reducing menstrual blood loss:

1. LNG-IUS (96% reduction) 2
2. Tranexamic acid (34-59% reduction) 2
3. NSAIDs (less than tranexamic acid) 2
4. Oral progestins (least effective medical option) 2, 6

Follow-Up Protocol

• Re-evaluate at 3-6 months after initiating treatment to assess efficacy 1
• Monitor hemoglobin and MCV every 3 months for 1 year, then annually 1
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained within normal ranges 1

Common Pitfalls to Avoid

• Do not use ergometrine for menorrhagia treatment—there is no evidence supporting its use 6
• Avoid prescribing progestins for more than 6 months due to meningioma risk 1, 4
• Do not assume all women with menorrhagia need coagulation disorder screening—this is only necessary in specific clinical contexts 3
• Tranexamic acid's most common adverse events are gastrointestinal (nausea, vomiting, diarrhea, dyspepsia in 12% of users), but these are generally well-tolerated 2