Treatment for Menorrhagia
First-Line Medical Therapy
The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective treatment for menorrhagia, reducing menstrual bleeding by 65-85% and improving quality of life, with approximately 50% of users developing amenorrhea or oligomenorrhea after 2 years of use. 1, 2
Alternative First-Line Options
When LNG-IUS is not suitable or desired, the following are effective alternatives:
Tranexamic acid 1.5-2g three times daily during menstruation reduces menstrual blood loss by 34-59% over 2-3 cycles and is particularly effective in women with bleeding disorders or coagulopathies 3, 1, 4
Combined oral contraceptives effectively regularize cycles and reduce bleeding by approximately 50%, making them suitable when contraception is also desired 3, 1, 2
NSAIDs (mefenamic acid 500mg three times daily or ibuprofen 400mg every 4-6 hours) for 5-7 days during bleeding episodes reduce menstrual blood loss by 20-50% 3, 5, 6, 2
Special Population Considerations
Adolescent Females
- Screen immediately for iron deficiency anemia, which affects 20-25% of adolescents with menorrhagia 3
- Tranexamic acid is first-line therapy in this population 3
- Combined oral contraceptives are effective for cycle regulation 3
- Oral progestins (norethindrone) should not be used for more than 6 months due to meningioma risk 3, 1
Women with Severe Thrombocytopenia
- Progestins may be useful but avoid depot medroxyprogesterone acetate (DMPA) due to irregular bleeding and 11-13 week irreversibility 1, 7
- Maximum duration of progestin use is 6 months to prevent meningioma development 3, 1
Anemia Management
All patients with menorrhagia require evaluation for iron deficiency anemia, as menorrhagia is the most common cause of iron deficiency in women of reproductive age 1
- Ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 3, 1
- Continue treatment for three months after correction of anemia to adequately replenish iron stores 3, 1
- Ascorbic acid can improve iron absorption in cases of insufficient response 1
Surgical Options
When medical therapy fails or is contraindicated:
Minimally Invasive Procedures
Uterine artery embolization (UAE) achieves 81-100% clinical success rates with symptom improvement in 83% of women at 3 months, though 20-25% experience symptom recurrence at 5-7 years 8, 1, 7
Endometrial ablation is appropriate for women who have completed childbearing, with >95% patient satisfaction 7
Hysteroscopic myomectomy is the treatment of choice for pedunculated submucous fibroids <5cm, offering shorter hospitalization and faster recovery 7
Definitive Treatment
- Hysterectomy provides definitive treatment with 90% satisfaction at 2 years but should be considered as a last option due to invasiveness and loss of fertility 7
Diagnostic Workup
Before initiating treatment, evaluate for:
- Iron deficiency anemia through hemoglobin and mean corpuscular volume (MCV) testing 1
- Uterine pathology (fibroids, polyps, adenomyosis) using ultrasound or MRI 1
- Coagulation disorders, particularly in women with severe thrombocytopenia 1
Monitoring and Follow-Up
- Monitor hemoglobin and MCV every 3 months for 1 year, then annually 3, 1
- Re-evaluate at 3-6 months after treatment initiation to assess efficacy 1
- Further investigation is only necessary if hemoglobin and MCV cannot be maintained within normal ranges 1
Important Caveats
- Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate and should not be used as first-line therapy 6
- Provide thorough counseling about expected bleeding patterns with any hormonal treatment to prevent non-adherence 3
- Women on anticoagulation (particularly rivaroxaban) have increased risk of prolonged menstrual bleeding and may require menorrhagia-specific interventions 8