What are the treatment options for a patient experiencing 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%, and should be offered as the primary option for most patients. 1, 2

Initial Assessment

Before initiating treatment, complete the following evaluation:

• Rule out pregnancy with beta-hCG testing in all reproductive-age women 1, 2
• Assess for structural causes including fibroids, polyps, adenomyosis, endometrial pathology, or malignancy using pelvic examination and transvaginal ultrasound 1, 3
• Screen for coagulopathies if clinically indicated, particularly in patients with flooding, clots ≥1 inch diameter, or personal/family bleeding history, as up to 20% of women with heavy menstrual bleeding may have an underlying bleeding disorder 2, 4, 5
• Check hemoglobin and ferritin levels to assess for anemia from blood loss 5
• Review current medications, especially anticoagulants or antiplatelet therapy that may contribute to bleeding 1

Treatment Algorithm

First-Line Treatment: LNG-IUD

The LNG-IUD (20 μg/day) is the most effective medical treatment, reducing menstrual blood loss by 71-95% and often resulting in light bleeding or amenorrhea over time 1, 2, 6. This device can be used through menopause in perimenopausal women and provides both treatment and contraception 2, 6.

Alternative First-Line: NSAIDs

For women not using the LNG-IUD, NSAIDs are the recommended first-line pharmacologic treatment, prescribed for 5-7 days during menstruation only 1, 2. Effective agents include mefenamic acid, naproxen, indomethacin, flufenamic acid, and diclofenac sodium, which reduce menstrual blood loss by 20-60% 2, 3, 7.

Critical contraindication: NSAIDs must be avoided in women with cardiovascular disease due to increased risk of myocardial infarction and thrombosis 1, 2. Screen for cardiovascular risk factors before initiating NSAID therapy 2.

Important caveat: Avoid aspirin, as it does not reduce bleeding and may actually increase blood loss 2.

Second-Line: Tranexamic Acid

Tranexamic acid is a non-hormonal alternative that reduces menstrual blood loss by approximately 80 mL per cycle (20-60% reduction) 2, 3, 7. This antifibrinolytic agent can be used orally or intravenously for acute bleeding 5.

Absolute contraindication: Tranexamic acid is contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease due to thrombosis risk 1, 2.

Additional Hormonal Options

• Combined hormonal contraceptives can be considered, though they are less effective than the LNG-IUD 2
• Cyclic oral progestin reduces bleeding by approximately 87%, though it may cause irregular bleeding patterns initially 6
• For patients with uterine fibroids: GnRH agonists or antagonists can reduce both bleeding symptoms and tumor volume, with combination low-dose estrogen-progestin FDA-approved for fibroid-related heavy menstrual bleeding 2

Special Populations

Perimenopausal Women

The LNG-IUD remains the most effective option and can be used through menopause 1, 2. Carefully assess cardiovascular and thrombotic risk factors when considering combined hormonal contraceptives in this population 1.

Adolescents with Acute Heavy Bleeding

Medical management is first-line; surgery should be reserved for non-responders 5. Use antifibrinolytics such as tranexamic acid or aminocaproic acid in oral or intravenous form to stop acute bleeding 5. After stabilization, maintenance therapy includes combined hormonal contraceptives, progestins, or LNG-IUD 5.

Patients with Bleeding Disorders

Heavy menstrual bleeding with flooding, prolonged menses, or personal/family bleeding history should prompt hematology referral 4. Hemostatic therapy may serve as an alternative to hormonal or surgical therapy and can be life-saving when correcting coagulation abnormalities 4.

When Medical Management Fails

If bleeding persists despite optimal medical therapy:

• Counsel on alternative medical options and offer different pharmacologic treatments 1
• Consider endometrial ablation as a conservative surgical option, which is more effective long-term than oral medical treatments 8, 1, 6
• Hysteroscopic myomectomy for submucosal fibroids in patients desiring uterus preservation 8
• Hysterectomy is definitive treatment when other options have failed 6

Common Pitfalls to Avoid

• Do not assume cyclic progestogens reduce bleeding in ovulating women—they are ineffective in this population 3
• Do not use NSAIDs or tranexamic acid in patients with cardiovascular disease—the thrombotic risk outweighs benefits 1, 2
• Do not proceed to surgery without attempting medical management first—drug treatment should be evaluated before surgical interventions 3
• Enhanced counseling about expected bleeding patterns improves treatment adherence, particularly with hormonal options that may cause initial irregular bleeding 2