What is the management for the onset of menorrhagia (heavy menstrual bleeding)?

From the Guidelines

For the management of onset heavy menstrual cycle, particularly in women with a history of spontaneous coronary artery dissection (SCAD), the use of a progestin-eluting intrauterine device, such as the levonorgestrel 20 μg/d–releasing device, is recommended as it can reduce menstrual blood loss by 71% to 95%. This approach is crucial because it not only manages heavy menstrual bleeding but also protects against pregnancy, which is often advised against in patients with SCAD due to the risks associated with both pregnancy and exogenous hormones 1.

When considering management options, it's essential to reassess the indication for ongoing antiplatelet therapy, which is commonly prescribed after SCAD, and discontinue its use if appropriate, as it can contribute to heavy menstrual bleeding 1. For women with hemodynamic instability or severe bleeding, urgent evaluation is warranted, and all reproductive-age women with abnormal uterine bleeding should be tested for pregnancy.

In the context of SCAD, medical management with hormonal therapy (HT) is relatively contraindicated, making non-hormonal options less favorable due to their association with myocardial infarction (MI) and thrombosis 1. Therefore, alternatives like nonsteroidal anti-inflammatory drugs (NSAIDs) and tranexamic acid, which are commonly used for heavy menstrual bleeding in other contexts, should be avoided in women with SCAD.

The levonorgestrel 20 μg/d–releasing device stands out as an effective approach for controlling bleeding, with minimal systemic progesterone levels but significant local effects at the endometrial level 1. Additionally, cyclic oral progestin treatment can reduce bleeding by 87%, although it may result in irregular bleeding and light menses 1. In cases where bleeding is not controlled, high-dose oral or injectable progestin-only medications may be considered for short-term use.

Given the unique considerations in managing heavy menstrual bleeding in women with SCAD, including the need to avoid pregnancy and exogenous hormones, conservative surgical treatments like second-generation endometrial ablation techniques may also be considered for their long-term efficacy in managing bleeding and reducing pregnancy risk 1.

From the FDA Drug Label

Progesterone capsules are used for the treatment of secondary amenorrhea (absence of menstrual periods in women who have previously had a menstrual period) due to a decrease in progesterone When you do not produce enough progesterone, menstrual irregularities can occur. Progesterone capsules may be given as a single daily dose of 400 mg at bedtime for 10 days.

The management for onset of heavy menstrual cycle is not directly addressed in the provided drug labels. However, progesterone capsules may be used to treat menstrual irregularities caused by a decrease in progesterone. The recommended dose for secondary amenorrhea is 400 mg at bedtime for 10 days.

• Key points:
  • Progesterone capsules may help with menstrual irregularities.
  • The dose for secondary amenorrhea is 400 mg at bedtime for 10 days.
  • There is no direct information on managing heavy menstrual cycles. 2

From the Research

Management Options for Heavy Menstrual Bleeding

• Heavy menstrual bleeding (HMB) can be managed with various medical treatments, including antifibrinolytics, nonsteroidal anti-inflammatory preparations, oral contraceptive pills, and oral, injectable, and intrauterine progestogens 3.
• Oral tranexamic acid and combined oral contraceptives (COC) have been shown to be equally effective in reducing menstrual blood loss in women with HMB 4, 5.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) can also reduce heavy menstrual bleeding, but are less effective than tranexamic acid or danazol 6, 7.

Efficacy of Different Treatments

• A study comparing oral tranexamic acid and COC found that both treatments were effective in reducing menstrual blood loss, with no significant difference between the two groups 4.
• Another study found that NSAIDs were more effective than placebo in reducing heavy menstrual bleeding, but less effective than tranexamic acid or danazol 6, 7.
• A pilot study in adolescents with HMB found that oral tranexamic acid and COC were equally effective in reducing menstrual blood loss and improving quality of life 5.

Considerations for Treatment Choice

• The choice of treatment for HMB should be based on individual patient factors, such as age, medical history, and preferences 3.
• Patients with leiomyomas may benefit more from COC than oral tranexamic acid 4.
• Adverse events should be considered when choosing a treatment, as some medications may have more severe side effects than others 4, 6, 7, 5.