What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

First-Line Treatment: Levonorgestrel-Releasing Intrauterine System (LNG-IUS)

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. 1, 2

• Approximately 50% of LNG-IUS users develop amenorrhea or oligomenorrhea after 2 years of use 1, 2
• This option is particularly suitable when long-term contraception is acceptable or desired 2

Alternative Medical Treatments Based on Clinical Context

When Contraception is Desired or Acceptable

Combined oral contraceptives are the preferred alternative to LNG-IUS, effectively regularizing cycles and reducing bleeding 1, 2

• Oral contraceptives produce significantly greater reduction in blood loss compared to NSAIDs, antifibrinolytics, or oral progestins 2
• This option addresses both menorrhagia and contraceptive needs simultaneously 1

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 1, 2, 3

• Reduces menstrual blood loss by 34-59% over 2-3 cycles 1, 2, 3
• Particularly effective in women with bleeding disorders or coagulopathies 1, 2
• Only needs to be taken during menstruation, not continuously 4, 5

NSAIDs (mefenamic acid 500mg three times daily or ibuprofen) are effective alternatives 3, 5

• Administer for 5-7 days during bleeding episodes 6, 3
• Have the additional benefit of reducing dysmenorrhea 4, 5
• Lower incidence of side effects compared to other options 4

Special Population: Severe Thrombocytopenia

Oral progestins (norethindrone) may be useful in women with severe thrombocytopenia 1, 3

• Critical caveat: Do not use progestins for more than 6 months due to meningioma risk 1, 2, 3
• Avoid depot medroxyprogesterone acetate (DMPA) in this population due to irregular bleeding and 11-13 week irreversibility 1

Essential Diagnostic Evaluation

Mandatory Initial Testing

Screen for iron deficiency anemia immediately, as menorrhagia is the most common cause of iron deficiency in women of reproductive age, affecting 20-25% of this population 1, 2, 3

• Evaluate for uterine pathology (fibroids, polyps, adenomyosis) using ultrasound or MRI 1
• Exclude coagulation disorders, particularly in women with severe thrombocytopenia 1

Anemia Management

Supplement with ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1, 2, 3

• Consider adding 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, 2, 3
• Monitor hemoglobin and MCV every 3 months for 1 year, then annually 1, 2, 3

Surgical Options When Medical Management Fails

Minimally Invasive Procedures

Endometrial ablation is appropriate for women who have completed childbearing, with satisfaction rates exceeding 95% 2

Uterine artery embolization (UAE) has an 81-100% clinical success rate 1, 2

• Symptom improvement occurs in 83% of women at 3 months 1, 2
• Important caveat: 20-25% risk of symptom recurrence at 5-7 years 1

Hysterectomy

• Reserved as treatment of last resort when other options have failed 7, 8
• Note that approximately 50% of hysterectomies performed for menorrhagia reveal no uterine pathology 5, 8

Treatment Algorithm Summary

1. If contraception desired: LNG-IUS first, combined oral contraceptives second 1, 2
2. If contraception not desired or hormones contraindicated: Tranexamic acid first, NSAIDs second 1, 2, 3
3. If severe thrombocytopenia: Oral progestins (maximum 6 months) 1, 2, 3
4. If medical management fails: Endometrial ablation or UAE for completed childbearing 1, 2
5. Always: Treat iron deficiency anemia concurrently 1, 2, 3

Follow-Up Protocol

Re-evaluate at 3-6 months after initiating treatment to assess efficacy 1, 2

• Monitor hemoglobin and erythrocyte indices every 3 months for 1 year, then annually 1, 2, 3
• Further investigation only necessary if hemoglobin and MCV cannot be maintained within normal ranges 1

Critical Pitfalls to Avoid

• Never prescribe progestins for more than 6 months due to meningioma risk 1, 2, 3
• Avoid DMPA in women with severe thrombocytopenia due to irregular bleeding and prolonged irreversibility 1
• Provide thorough counseling about expected bleeding patterns with hormonal treatments to prevent non-adherence 3
• Do not use ergometrine for menorrhagia treatment—it has no established role 4