What are the treatment options for menorrhagia?

Treatment Options for Menorrhagia

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, with approximately 50% of users achieving amenorrhea or oligomenorrhea after 2 years. 1, 2

Treatment Algorithm Based on Clinical Context

When Contraception is Desired or Acceptable

• LNG-IUS remains the gold standard, providing both contraception and the greatest reduction in menstrual blood loss compared to all other medical therapies 2
• Combined oral contraceptives are an effective alternative, regularizing cycles and significantly reducing bleeding compared to NSAIDs, antifibrinolytics, or oral progestins 1, 2, 3
• These hormonal options are particularly suitable when dual benefits of bleeding control and contraception are needed 3

When Contraception is Not Desired or Hormonal Therapy is Contraindicated

• Tranexamic acid (1.5-2g three times daily during menstruation only) is the first-line non-hormonal option, reducing menstrual blood loss by 34-59% over 2-3 cycles 1, 2, 4
• This antifibrinolytic agent is particularly effective in women with bleeding disorders or coagulopathies 1, 2
• NSAIDs (mefenamic acid 500mg three times daily or ibuprofen) for 5-7 days during bleeding reduce blood loss by 25-35% and have the added benefit of treating dysmenorrhea 5, 4, 6
• Prostaglandin synthesis inhibitors have the lowest incidence of side effects among medical treatments 3

Special Population: Adolescents

• Tranexamic acid is recommended as first-line therapy in adolescent females with menorrhagia 5
• NSAIDs (mefenamic acid or ibuprofen) for 5-7 days during bleeding episodes are appropriate alternatives 5
• Combined oral contraceptives effectively regularize cycles and reduce bleeding in this age group 5

Special Population: Women with Severe Thrombocytopenia

• Oral progestins (norethindrone) may be useful but should not be used for more than 6 months due to meningioma risk 1, 2, 5
• Avoid depot medroxyprogesterone acetate (DMPA) due to irregular bleeding patterns and 11-13 week irreversibility 1

Essential Diagnostic Evaluation Before Treatment

• 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, 5
• Search 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, 5
• Consider adding ascorbic acid to improve iron absorption in cases of insufficient response 1
• Continue treatment for three months after correction of anemia to replenish iron stores 1, 2, 5

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, with symptom improvement in 83% of women at 3 months 1, 2
• However, there is a 20-25% risk of symptom recurrence at 5-7 years with UAE 1

Hysterectomy

• Reserved as treatment of last resort when medical and conservative surgical options have failed 7
• Accounts for two-thirds of all hysterectomies performed 4

Follow-Up Protocol

• Re-evaluate at 3-6 months after initiating treatment to assess efficacy 1, 2
• Monitor hemoglobin and mean corpuscular volume (MCV) every 3 months for 1 year, then annually 1, 2, 5
• Further investigation is 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, 5
• Avoid DMPA in women with severe thrombocytopenia due to irregular bleeding and prolonged irreversibility 1
• Provide thorough counseling about expected bleeding patterns with any hormonal treatment to prevent non-adherence 5
• Recognize that oral progestogens achieve only a 20% reduction in blood loss in ovulatory women, questioning their use as first-line treatment 6
• Ergometrine has no place in the treatment of menorrhagia 3