What is the management for postpartum heavy menstruation (menorrhagia)?

Management of Postpartum Heavy Menstruation

For postpartum heavy menstruation (menorrhagia), the levonorgestrel-releasing intrauterine system (LNG-IUS) should be the first-line treatment, as it reduces menstrual blood loss comparably to endometrial ablation or hysterectomy while preserving fertility. 1, 2, 3

Initial Assessment and Diagnosis

• Obtain a detailed menstrual history focusing on cycle regularity, duration of bleeding, number of pads/tampons used, and presence of clots to assess severity 4, 2
• Perform a bleeding score assessment to identify women who may have an underlying inherited bleeding disorder (present in up to 20% of women with heavy menstrual bleeding) 2
• Conduct pelvic examination and transvaginal ultrasound to exclude structural pathology such as retained products of conception, fibroids, or endometrial polyps 4, 3
• Check hemoglobin levels to assess for anemia, which commonly accompanies menorrhagia 4, 3

Medical Management Algorithm

First-Line Therapy

The LNG-IUS is the most effective medical treatment, reducing menstrual blood loss by 71-96% and demonstrating efficacy comparable to surgical interventions 1, 2, 3. The 2010 U.S. Medical Eligibility Criteria specifically notes that the LNG-IUS is beneficial in treating menorrhagia and can be used even in women with heavy or prolonged bleeding 1.

Second-Line Medical Options (if LNG-IUS contraindicated or declined)

• Tranexamic acid 1-1.5g three times daily during menstruation reduces menstrual blood loss by 40-60% through antifibrinolytic action 4, 2, 3
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid 500mg three times daily during menstruation reduce blood loss by 20-50% 4, 2, 3
• Combined hormonal contraceptives (pills, patch, or ring) can reduce menstrual blood loss, though less effectively than LNG-IUS 1, 2

Combination Therapy

Tranexamic acid or NSAIDs can be combined with hormonal treatments for women requiring additional bleeding control 2

Surgical Management

When to Consider Surgery

Surgical intervention should only be considered after medical therapies have been tried and failed, or when structural pathology requiring surgical correction is identified 3

Surgical Options in Order of Invasiveness

1. Hysteroscopic resection of retained placental tissue if present, though this may require multiple procedures (50% need more than one procedure) and carries risk of uterine perforation 1

2. Endometrial ablation is a minimally invasive outpatient procedure with low operative morbidity, suitable when fertility is no longer desired 4, 2

   • Critical caveat: Endometrial ablation is associated with high risk of pregnancy complications if pregnancy occurs afterward 1

3. Hysterectomy remains the definitive treatment when all other options have failed and is the only treatment guaranteeing cessation of menstruation 4, 2

Special Considerations for Postpartum Context

• Rule out retained products of conception using ultrasound, which will show an echogenic endometrial mass with vascularity 5
• Exclude ongoing postpartum hemorrhage (defined as blood loss >500 mL vaginal delivery or >1000 mL cesarean) which requires different acute management with tranexamic acid 1g IV and uterotonics 6, 5
• Assess for postpartum complications including infection, which may present with heavy bleeding 1

Common Pitfalls to Avoid

• Do not use cyclic progestogens alone in ovulating women, as they do not significantly reduce menstrual bleeding 3
• Avoid routine use of methotrexate for retained placental tissue, as it has unproven benefit, potential for severe toxicity (including maternal death), and is contraindicated in breastfeeding 1
• Do not delay treatment while waiting for laboratory results if the patient is hemodynamically unstable 5
• Ensure proper contraception counseling before endometrial ablation, as pregnancy afterward carries significant risks 1

Quality of Life Impact

Effective treatment of menorrhagia substantially improves physical, emotional, and social wellbeing 4, 2. The LNG-IUS achieves this with minimal intervention and preserves future fertility options, making it the optimal first choice for most postpartum women experiencing heavy menstruation 1, 2, 3.