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%. 1

First-Line Medical Therapies

Tranexamic Acid (Preferred)

• Tranexamic acid is the most effective non-hormonal option, reducing menstrual blood loss by 54% compared to baseline. 2
• Dosing: 1.5-2g three times daily for 5 days during menstruation 1
• This antifibrinolytic agent works by blocking plasminogen and preventing fibrin degradation 3
• Treatment effects are seen over 2-3 menstrual cycles 1, 3
• In head-to-head trials, tranexamic acid significantly outperformed mefenamic acid, flurbiprofen, etamsylate, and oral luteal phase norethisterone 3, 2

Mefenamic Acid (Alternative First-Line)

• Dosing: 500mg three times daily for 5-7 days during bleeding episodes 1
• Reduces menstrual blood loss by 20% 1, 2
• This NSAID is less effective than tranexamic acid but remains a reasonable first-line option when tranexamic acid is contraindicated 2
• Other NSAIDs like ibuprofen 600-800mg every 6-8 hours can be used, though evidence is stronger for mefenamic acid specifically for menorrhagia 4

Second-Line Hormonal Therapies

Combined Oral Contraceptives

• Can be used for 10-20 days during bleeding episodes to regularize cycles and reduce bleeding 1
• Particularly useful when contraception is also desired 5
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1

Progestins

• Norethindrone may be useful in specific populations 1
• Critical caveat: Should not be used for more than 6 months due to meningioma risk 1
• Cyclic progestogens are notably ineffective in ovulating women and should be avoided in this population 5

Levonorgestrel Intrauterine System (Most Effective Overall)

• The hormonal IUS is the most effective medical treatment, reducing menstrual blood loss by 96% at 12 months 3
• Effectiveness is comparable to endometrial ablation or hysterectomy 5
• Important caveat: 44% of patients develop amenorrhea, which may be unacceptable to some women 3
• Intermenstrual bleeding is a common adverse event that should be discussed during counseling 3

Management of Associated Anemia

• Screen all patients with menorrhagia immediately for iron deficiency anemia, as it affects 20-25% of this population 1
• Ferrous sulfate 200mg three times daily should be continued for 3 months after correction of anemia to replenish iron stores 1

Evaluation for Underlying Pathology

Before initiating treatment, rule out: 1

• Structural abnormalities (fibroids, polyps, adenomyosis)
• Pregnancy
• Sexually transmitted infections
• Drug interactions
• Endometrial hyperplasia or malignancy (especially in women >40 years)

Vaginal sonography is the most important supplemental examination when menstrual pattern has changed substantially or anemia is present 5

Surgical Options

When to Consider Surgery

• After failure of medical treatment 6, 5
• When medical treatment is unacceptable to the patient 1
• When underlying structural pathology requires surgical intervention 6

Surgical Approaches

• Endometrial ablation: Effectiveness comparable to levonorgestrel IUS 5
• Uterine fibroid embolization: For fibroid-associated menorrhagia, with equivalent symptomatic improvement to myomectomy at 2 years 1
• Hysterectomy: Definitive treatment with high satisfaction rates but carries surgical morbidity 1

Treatment Algorithm

1. Rule out underlying pathology (pregnancy, STIs, structural abnormalities, malignancy) 1
2. Screen for and treat iron deficiency anemia 1
3. Start tranexamic acid 1.5-2g three times daily for 5 days during menstruation 1
4. If tranexamic acid fails or is contraindicated, use mefenamic acid 500mg three times daily 1
5. If non-hormonal options fail, consider levonorgestrel IUS (most effective) or combined oral contraceptives 1, 5
6. Reserve surgical options for medical treatment failures or when structural pathology requires intervention 1, 5

Common Pitfalls to Avoid

• Do not use cyclic progestogens in ovulating women—they are ineffective for reducing menstrual blood loss 5
• Do not use norethindrone for more than 6 months due to meningioma risk 1
• Do not proceed to surgery without attempting medical management first 5, 2
• Do not forget to counsel patients about expected bleeding patterns with hormonal treatments to prevent non-adherence 1
• The most common adverse events with tranexamic acid are gastrointestinal (nausea, vomiting, diarrhea, dyspepsia) occurring in 12% of patients, though this is not significantly different from placebo 3