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

Treatment for Menorrhagia During Menses

For women with heavy menstrual bleeding, start with combined oral contraceptives containing 30-35 μg ethinyl estradiol as first-line therapy, or alternatively use tranexamic acid 1.5-2g three times daily for 5 days during menstruation if hormonal contraception is contraindicated. 1, 2

Initial Evaluation Before Treatment

Before initiating any therapy, you must:

• Rule out pregnancy with β-hCG testing in all reproductive-age women 1
• Screen for sexually transmitted infections, particularly in reproductive-aged women 1
• Perform transvaginal ultrasound to identify polyps, fibroids, adenomyosis, or endometrial abnormalities 1
• Check TSH levels to exclude thyroid dysfunction causing ovulatory abnormalities 1
• Screen for bleeding disorders (von Willebrand disease) if there is personal/family history of easy bruising, epistaxis, dental bleeding, or if bleeding is refractory to initial treatment 1
• Test for iron deficiency anemia immediately, as it affects 20-25% of patients with menorrhagia 2

First-Line Medical Treatment Options

Option 1: Combined Oral Contraceptives (Preferred)

Monophasic combined oral contraceptives with 30-35 μg ethinyl estradiol are the initial therapy of choice, reducing menstrual blood loss by inducing regular shedding of a thinner endometrium 1. These also improve acne and reduce the risk of endometrial and ovarian cancers 1.

Critical caveat: Before prescribing, assess thrombotic risk factors as COCs increase venous thromboembolism risk three to fourfold 1. COCs are contraindicated in women with active thromboembolic disease or significant risk factors 3.

Option 2: Tranexamic Acid (Most Effective Non-Hormonal)

Tranexamic acid 1.5-2g three times daily for 5 days during menstruation reduces menstrual blood loss by 34-59% over 2-3 cycles and is the most effective non-hormonal option 2, 4. It reduces bleeding by 40-60% 1.

Absolute contraindication: Do not use in women with active thromboembolic disease or history/risk of thrombosis 1, 5. Tranexamic acid is an antifibrinolytic agent that stabilizes fibrin and prevents its dissolution by plasmin 5.

Option 3: NSAIDs

Mefenamic acid 500mg three times daily for 5-7 days during bleeding episodes reduces menstrual blood loss by 20-60% 3, 1, 2, 6. Other NSAIDs like naproxen or ibuprofen are also effective 6.

Important: Aspirin should be avoided as it can paradoxically increase bleeding 1. NSAIDs work by reducing elevated prostaglandin levels in women with excessive menstrual bleeding 6.

If First-Line Treatment Fails

Add-On Therapy for Persistent Bleeding on COCs

If bleeding persists while on COCs:

• Add NSAIDs for 5-7 days during bleeding episodes 1
• Alternatively, add hormonal treatment for 10-20 days if medically eligible 3, 1

Most Effective Long-Term Option

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment, reducing menstrual blood loss by 71-95% 3, 1, 4. Its efficacy is comparable to endometrial ablation or hysterectomy 3, 1.

The LNG-IUS works primarily at the endometrial level with minimal systemic progesterone absorption 3. This is particularly useful for women who cannot tolerate systemic hormones or have contraindications to estrogen-containing contraceptives.

Treatment Algorithm for Contraceptive-Related Bleeding

If the patient is already using contraception and develops menorrhagia, the CDC provides specific guidance 3:

• For Cu-IUD users: NSAIDs for 5-7 days during bleeding 3
• For implant users with heavy bleeding: NSAIDs for 5-7 days, hormonal treatment (low-dose COCs or estrogen) for 10-20 days, or antifibrinolytics (tranexamic acid) for 5 days 3
• For DMPA users: NSAIDs for 5-7 days, or hormonal treatment with low-dose COCs or estrogen for 10-20 days 3

Critical Counseling Points

Reassure patients that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and is generally not harmful 3, 1. Enhanced counseling about expected bleeding patterns significantly reduces discontinuation rates 3, 1.

For Cu-IUD users specifically, unscheduled spotting or heavy bleeding is common during the first 3-6 months and decreases with continued use 3.

Management of Associated Anemia

Iron supplementation with ferrous sulfate 200mg three times daily should be continued for 3 months after correction of anemia to replenish iron stores 2.

When to Consider Surgical Options

If medical management fails or is unacceptable:

• Hysterectomy is definitive with high satisfaction rates but carries surgical morbidity 2
• Uterine fibroid embolization for fibroid-associated menorrhagia shows equivalent symptomatic improvement to myomectomy at 2 years 2
• Endometrial ablation has comparable efficacy to the LNG-IUS 1, 4

Common Pitfalls to Avoid

1. Do not use cyclic oral progestogens as first-line therapy—they do not significantly reduce menstrual bleeding in women who ovulate 4
2. Do not combine tranexamic acid with hormonal contraceptives due to increased thromboembolic risk 5
3. Do not prescribe norethindrone for more than 6 months due to meningioma risk 2
4. Always exclude underlying pathology (fibroids, polyps, endometrial abnormalities, infections, pregnancy) before attributing bleeding to hormonal causes 3, 1