What are the treatment options for a patient with menorrhagia (heavy menstrual bleeding)?

Treatment of Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95%. 1, 2

Initial Assessment

Before initiating treatment, complete the following evaluation:

• Rule out pregnancy in all reproductive-age women presenting with abnormal bleeding 1
• Exclude structural causes including fibroids, polyps, adenomyosis, endometrial pathology, or malignancy through pelvic examination and imaging 1
• Screen for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1, 2
• Review current medications, particularly anticoagulants or antiplatelet therapy that may contribute to bleeding 1

First-Line Treatment Algorithm

For Women Desiring Long-Term Solution or Contraception

Offer LNG-IUD as first-line therapy, which reduces menstrual blood loss by 71-95% and provides the most effective bleeding reduction among medical options 1, 2, 3. This device can be used through menopause in perimenopausal women 1, 4.

For Women Seeking Short-Term Symptom Management

Prescribe NSAIDs (naproxen or mefenamic acid) for 5-7 days during menstruation only, which reduce menstrual blood loss by 20-60% 1, 2, 5. NSAIDs are effective regardless of whether bleeding is anovulatory or ovulatory 4.

Critical caveat: Avoid NSAIDs in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 1. Do not use aspirin as it may paradoxically increase bleeding 4.

For Women Requiring Non-Hormonal Options

Consider tranexamic acid if NSAIDs are ineffective, which reduces bleeding by 40-60% 4, 3. Tranexamic acid is more effective than NSAIDs but less effective than LNG-IUD 3, 5.

Absolute contraindication: Do not use tranexamic acid in women with active thromboembolism, history of thrombosis, or cardiovascular disease due to thrombosis risk 1, 4.

Second-Line Treatment Options

If first-line treatments fail or are contraindicated:

• Cyclic oral progestogens reduce bleeding by approximately 87%, though may cause irregular bleeding patterns 2
• Combined hormonal contraceptives effectively reduce menstrual blood loss when hormonal options are appropriate 2
• Carefully assess cardiovascular and thrombotic risk factors before using combined hormonal contraceptives, especially in perimenopausal women 1, 4

Surgical Options When Medical Management Fails

If bleeding persists despite optimal medical therapy:

• Endometrial ablation (resectoscopic or non-resectoscopic techniques) results in large reduction of menstrual blood loss, with non-resectoscopic endometrial ablation showing moderate certainty evidence for effectiveness 1, 3
• Hysterectomy (minimally invasive preferred) provides the highest bleeding reduction and satisfaction rates among all treatments, with minimally invasive approaches resulting in large increases in patient satisfaction 3

Treatment Ranking by Effectiveness

Based on network meta-analysis of 26 studies with 1770 participants 3:

1. LNG-IUD: Mean reduction of 105.71 mL/cycle (low certainty evidence)
2. Antifibrinolytics (tranexamic acid): Mean reduction of 80.32 mL/cycle (moderate certainty evidence)
3. Long-cycle progestogens: Mean reduction of 76.93 mL/cycle (low certainty evidence)
4. NSAIDs: Mean reduction of 40.67 mL/cycle (low certainty evidence)

Common Pitfalls to Avoid

• Do not dismiss early IUD-related bleeding: Bleeding in the first 3-6 months of IUD use is common and generally not harmful; treat with NSAIDs for 5-7 days 4
• Do not use luteal-phase progestogens as first-line: Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 6
• Re-evaluate if bleeding persists: New-onset prolonged bleeding after months of stable IUD use requires evaluation for displacement, infection, pregnancy, or new uterine pathology 4