What is the best treatment approach for a female patient with menorrhagia (excessive menstrual bleeding) and a regular menstrual cycle?

Management of Menorrhagia with Regular Cycles

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for menorrhagia with regular cycles, reducing menstrual blood loss by up to 96% after 12 months. 1

Initial Diagnostic Evaluation

Mandatory Laboratory Testing

• Screen immediately for iron deficiency anemia, as menorrhagia is the most common cause of iron deficiency in women of reproductive age, affecting 20-25% of this population. 1, 2
• Measure hemoglobin and mean corpuscular volume (MCV) at baseline. 2
• Consider imaging (ultrasound or MRI) to evaluate for structural pathology including fibroids, polyps, or adenomyosis. 2
• Exclude coagulation disorders, particularly in women presenting with severe bleeding or bleeding since menarche. 2

Treatment Algorithm

First-Line Medical Management

When contraception is desired or acceptable:

• LNG-IUS is the gold standard, with approximately 50% of users developing amenorrhea or oligomenorrhea after 2 years of use. 1, 2
• Combined oral contraceptives are an effective alternative, regularizing cycles and reducing bleeding significantly compared to NSAIDs, antifibrinolytics, or oral progestins. 1, 2

When contraception is not desired or hormonal therapy is contraindicated:

• Tranexamic acid (1.5-2g three times daily during menstruation) is the first-line non-hormonal option, reducing menstrual blood loss by 34-59% over 2-3 cycles. 1, 3
• This is particularly effective in women with bleeding disorders or coagulopathies. 1, 2

Alternative non-hormonal options:

• NSAIDs such as mefenamic acid 500mg three times daily for 5-7 days during bleeding episodes reduce menstrual blood loss by 20-35%. 2, 3
• Mefenamic acid is the most frequently studied NSAID for menorrhagia and is suitable for women wishing to avoid hormonal treatment. 2, 4

Anemia Management (Concurrent with Bleeding Treatment)

• Supplement with ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores. 1, 2, 3
• Consider adding ascorbic acid to improve iron absorption in cases of insufficient response. 2
• Continue iron supplementation for three months after correction of anemia to replenish iron stores. 1, 2, 3

Critical Pitfall to Avoid

Do not prescribe oral progestins (such as norethindrone) for more than 6 months due to meningioma risk. 1, 2, 3 While progestins may be useful in specific situations like severe thrombocytopenia, their long-term use carries significant risk. 2

Second-Line Options When Medical Management Fails

Minimally Invasive Surgical Procedures

• Endometrial ablation is appropriate for women who have completed childbearing, with satisfaction rates exceeding 95%. 1
• Uterine artery embolization (UAE) has an 81-100% clinical success rate, with symptom improvement in 83% of women at 3 months. 1, 2
• Be aware that UAE carries a 20-25% risk of symptom recurrence at 5-7 years. 2

Hysterectomy

• Reserved as the definitive treatment when all other options have failed or are unacceptable to the patient. 5, 6

Follow-Up Protocol

• Re-evaluate at 3-6 months after initiating treatment to assess efficacy. 1, 2
• Monitor hemoglobin and MCV every 3 months for 1 year, then annually. 1, 2, 3
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained within normal ranges despite treatment. 2

Evidence Quality Note

The LNG-IUS recommendation is based on the American College of Obstetricians and Gynecologists guidelines showing superior efficacy compared to all other medical options. 1 Tranexamic acid represents the best non-hormonal alternative with robust evidence for efficacy. 1, 4 While older research supports NSAIDs and other options, they demonstrate inferior efficacy compared to LNG-IUS and tranexamic acid. 4, 7, 5