What are the recommended outpatient treatments for menorrhagia (heavy menstrual bleeding)?

Outpatient Treatment for Menorrhagia

First-Line Medical Therapy

For outpatient management of menorrhagia, begin with either NSAIDs (5-7 days during menses), tranexamic acid, or combined oral contraceptives (30-35 μg ethinyl estradiol), with the levonorgestrel intrauterine system (LNG-IUS) being the most effective option when contraception is acceptable. 1, 2

Treatment Algorithm Based on Contraceptive Needs

If Contraception Desired:

• Levonorgestrel IUD (LNG-IUS): Most effective medical treatment, with efficacy comparable to endometrial ablation or hysterectomy 2

  • Reduces menstrual blood loss by up to 96% over time 2
  • Many women develop amenorrhea or oligomenorrhea by 2 years of use 3

• Combined Oral Contraceptives (COCs): Monophasic formulations with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1

  • Decrease menstrual blood loss by inducing regular shedding of thinner endometrium 1
  • Extended/continuous regimens (3-4 months of active pills) particularly useful for severe menorrhagia and anemia 1
  • Additional benefits include acne improvement and reduced risk of endometrial/ovarian cancers 1

If Contraception NOT Desired:

• Tranexamic Acid: Reduces menstrual blood loss by 40-60% 4, 2

  • Taken only during menstruation (5-7 days) 2
  • Critical contraindication: Active thromboembolic disease or history/risk of thrombosis 5
  • Avoid concomitant use with hormonal contraceptives due to increased thrombotic risk 5

• NSAIDs (Mefenamic Acid, Ibuprofen): Reduce blood loss by 20-50% 2

  • Taken during menstruation only (5-7 days) 3
  • Lowest incidence of side effects among medical options 6
  • Additional benefit of reducing dysmenorrhea 6
  • Multiple studies demonstrate significant reductions in menstrual blood loss with various NSAIDs including mefenamic acid, flufenamic acid, and diclofenac 3

Second-Line Options

• Depot Medroxyprogesterone Acetate (DMPA): Consider when first-line options fail 1
  • Amenorrhea common after ≥1 year of use 3
  • For breakthrough heavy bleeding with DMPA, use NSAIDs for 5-7 days 3, 1

Management of Breakthrough Bleeding

With COCs:

• Consider NSAIDs for 5-7 days during bleeding episodes 1
• If using extended regimens, allow 3-4 day hormone-free interval (but not during first 21 days and not more than once monthly) 1

With LNG-IUD:

• Heavy bleeding uncommon but if occurs, rule out displacement, STD, pregnancy, or new pathology (polyps, fibroids) 3
• No specific pharmacologic treatment recommended; consider alternative contraceptive if unacceptable 3

Critical Exclusions Before Treatment

Before initiating any therapy, rule out:

• Pregnancy or incomplete abortion 7
• Thyroid dysfunction (check TSH) 7
• Bleeding disorders 7
• Structural abnormalities: fibroids, polyps (vaginal sonography recommended) 2
• Endometrial hyperplasia or carcinoma (especially age >40) 2
• STDs 3

Important Safety Considerations

Tranexamic Acid Warnings:

• Absolute contraindication: Active intravascular clotting, history of thromboembolism 5
• May cause seizures, particularly at high doses 5
• Hypersensitivity reactions including anaphylaxis reported 5
• May cause dizziness; advise caution with driving 5

COC Considerations:

• Increases VTE risk 3-4 fold (up to 4 per 10,000 woman-years) 1
• Monitor blood pressure at follow-up 1
• Smoking NOT a contraindication in women <35 years 1
• Does not increase infertility or breast cancer risk 1

Common Pitfalls to Avoid

• Do not use aspirin: Studies show no benefit and potential increase in bleeding with lower baseline blood loss 3
• Do not use cyclic progestogens alone: Ineffective for reducing menstrual bleeding in ovulating women 2
• Avoid combining tranexamic acid with hormonal contraceptives: Increased thrombotic risk 5
• Do not use ergometrine: No place in menorrhagia treatment 6

Treatment Hierarchy

The evidence supports this order of effectiveness:

1. LNG-IUS (most effective, 80-96% reduction) 2
2. Tranexamic acid (40-60% reduction) 4, 2
3. NSAIDs (20-50% reduction, best side effect profile) 6, 2
4. COCs (effective but less data on exact reduction percentage) 1

Antifibrinolytics (tranexamic acid) reduce menstrual blood loss to the greatest extent among non-IUD options, while NSAIDs have the lowest incidence of side effects. 6