What are the treatment options for menorrhagia?

Treatment of Menorrhagia

Tranexamic acid 1.5-2g three times daily for 5 days during menstruation is the first-line medical treatment for menorrhagia, reducing menstrual blood loss by 34-59% over 2-3 cycles. 1, 2, 3

First-Line Medical Therapies

Tranexamic Acid (Preferred)

• Dosing: 1.5-2g three times daily (total 4.5-6g/day) for 5 days starting on day 1 of menstruation 1, 2, 3
• Efficacy: Reduces menstrual blood loss by 54% compared to baseline, significantly superior to mefenamic acid (20% reduction) and ethamsylate (no reduction) 3
• Mechanism: Antifibrinolytic agent that prevents fibrin degradation by blocking plasminogen binding sites 4
• Safety profile: Most common adverse effects are gastrointestinal (nausea, vomiting, diarrhea) occurring in 12% of patients, similar to placebo rates 2
• Important contraindications: Avoid in patients with thromboembolic risk, seizure history, or active visual disturbances 4

NSAIDs (Alternative First-Line)

• Mefenamic acid: 500mg three times daily for 5-7 days during bleeding episodes 5, 1, 3
• Ibuprofen: Alternative NSAID option for 5-7 days during menstruation 1
• Efficacy: Reduces menstrual blood loss by 20%, less effective than tranexamic acid but still beneficial 3
• Additional benefit: Provides relief from dysmenorrhea 2

Second-Line Hormonal Therapies

Levonorgestrel-Releasing Intrauterine Device (Most Effective)

• Efficacy: Produces the greatest reduction in menstrual blood loss (96% after 12 months), though 44% of patients develop amenorrhea 2
• Best for: Women desiring long-term contraception and fertility preservation who can accept potential amenorrhea 6
• Consideration: High satisfaction rates but amenorrhea and intermenstrual bleeding may be unacceptable to some patients 2

Combined Oral Contraceptives

• Use: Effective for regularizing cycles and reducing bleeding in women with menorrhagia 1
• Duration: Can be used for 10-20 days during bleeding episodes if medically eligible 5
• Caution: Risk of thromboembolic events when combined with tranexamic acid; avoid concurrent use 4

Oral Progestins

• Norethindrone: May be useful in specific populations (e.g., severe thrombocytopenia) 1
• Critical limitation: Should not be used for more than 6 months due to meningioma risk 1
• Evidence: Oral luteal phase norethisterone is less effective than tranexamic acid 2

Management of Associated Anemia

Iron Supplementation

• Dosing: Ferrous sulfate 200mg three times daily 1
• Duration: Continue for 3 months after correction of anemia to replenish iron stores 1
• Screening: Test for iron deficiency anemia immediately in all patients with menorrhagia, as it affects 20-25% of this population 1
• Monitoring: Check hemoglobin and MCV every 3 months for 1 year, then annually 1

Evaluation for Underlying Pathology

Before initiating treatment, consider underlying gynecological problems including:

• Structural abnormalities: Polyps, fibroids, or other pathologic uterine conditions 5
• Infections: Screen for sexually transmitted diseases 5
• Pregnancy: Rule out pregnancy if clinically indicated 5
• Drug interactions: Medications that may affect bleeding patterns 5

Surgical Options (When Medical Management Fails)

Endometrial Ablation

• Indication: For women who have completed childbearing and failed medical therapy 6
• Outcome: High satisfaction rates with uterine preservation 6

Hysterectomy

• Indication: Definitive treatment when other options fail or are unacceptable 5, 6
• Outcome: Highest satisfaction rates but with potential surgical morbidity 6
• Context: Accounts for two-thirds of all hysterectomies, with approximately 50% showing no pathology at surgery 7

Uterine Fibroid Embolization

• Indication: For fibroid-associated menorrhagia 5
• Evidence: Equivalent symptomatic improvement to myomectomy at 2 years 5

Treatment Algorithm

1. Screen immediately for iron deficiency anemia 1
2. Start tranexamic acid 1.5-2g three times daily for 5 days during menstruation as first-line therapy 1, 3
3. Alternative: Use mefenamic acid 500mg three times daily if tranexamic acid is contraindicated or not tolerated 1, 3
4. Add iron supplementation (ferrous sulfate 200mg three times daily) if anemia is present 1
5. Consider levonorgestrel IUD for long-term management if contraception is desired and amenorrhea is acceptable 2, 6
6. Escalate to surgical options (endometrial ablation or hysterectomy) if medical management fails and childbearing is complete 6

Critical Counseling Points

• Provide thorough counseling about expected bleeding patterns with any hormonal treatment to prevent non-adherence 1
• Emphasize that tranexamic acid must be taken during menstruation only, not continuously 4, 2
• Warn patients about gastrointestinal side effects with tranexamic acid, which may resolve with dose reduction 4
• Discuss that 81% of women report satisfaction with tranexamic acid therapy, with 94% reporting decreased menstrual blood loss 2