What is the initial management for a female patient of reproductive age with regular menstrual cycles and menorrhagia?

Differential Diagnosis and Initial Management of Menorrhagia with Regular Cycles

Primary Recommendation

The levonorgestrel-releasing intrauterine system (LNG-IUS) should be offered as first-line treatment for menorrhagia with regular cycles, as it reduces menstrual blood loss by up to 96% after 12 months and achieves amenorrhea or oligomenorrhea in approximately 50% of users after 2 years 1, 2.

Differential Diagnosis to Exclude

Before initiating treatment, rule out the following structural and systemic causes:

Structural Abnormalities

• Uterine fibroids (most common in women under 40 years) 3
• Endometrial polyps (most common in women over 40 years) 3
• Adenomyosis (may coexist with fibroids) 4
• Endometrial hyperplasia or carcinoma (especially in women over 45 years) 2

Systemic Causes

• Coagulopathies and bleeding disorders (von Willebrand disease, platelet dysfunction) 1
• Thyroid dysfunction (hypothyroidism or hyperthyroidism) 5
• Hepatic or renal dysfunction 5
• Medication effects (anticoagulants, psychotropic medications) 5

Essential Initial Workup

Mandatory Laboratory Testing

• Complete blood count to screen for iron deficiency anemia, which affects 20-25% of women with menorrhagia 1
• Thyroid stimulating hormone (TSH) to evaluate thyroid function 5
• Pregnancy test to rule out pregnancy-related bleeding 5

Imaging Studies

• Transvaginal ultrasound as first-line imaging modality 2
• Saline infusion sonohysterography if intracavitary pathology is suspected (96-100% sensitivity for detecting intracavitary lesions) 2
• Endometrial biopsy mandatory in women over 45 years regardless of ultrasound findings 2

Medical Management Algorithm

First-Line: When Contraception is Desired or Acceptable

Option 1: Levonorgestrel-releasing IUS (LNG-IUS)

• Most effective medical treatment with 96% reduction in menstrual blood loss 1, 2
• Provides dual benefit of contraception and bleeding control 1

Option 2: Combined Oral Contraceptives

• Regularize cycles and significantly reduce bleeding 1, 2
• More effective than NSAIDs, antifibrinolytics, or oral progestins 1

First-Line: When Contraception Not Desired or Hormonal Therapy Contraindicated

Tranexamic Acid

• Dose: 1.5-2g three times daily during menstruation 1, 2
• Reduces menstrual blood loss by 34-59% over 2-3 cycles 1, 2
• Particularly effective in women with bleeding disorders or coagulopathies 1
• Supported by the most robust clinical trial data for non-hormonal treatment 6

Second-Line Medical Options

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Reduce menstrual blood loss by 20-60% 3, 7
• Mefenamic acid is commonly used 7
• Greater proportional reduction seen in women with more excessive bleeding 8

Important Caveat: Avoid prescribing progestins for more than 6 months due to meningioma risk 1. Cyclic progestogens achieve only 20% reduction in blood loss in ovulatory women and should not be first-line 8.

Anemia Management Protocol

• Ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1, 2
• Continue iron supplementation for three months after hemoglobin normalization to replenish body stores 1, 2
• Consider adding ascorbic acid to enhance iron absorption if response is poor 2

Surgical Options When Medical Management Fails

Minimally Invasive Procedures

• Endometrial ablation for women who have completed childbearing (satisfaction rates exceeding 95%) 1, 2
• Uterine artery embolization (UAE) with 81-100% clinical success rate and symptom improvement in 83% at 3 months 1, 2

Special Consideration for Fibroids

• Medical management should be trialed first before pursuing invasive therapies 4
• Laparoscopic or open myomectomy, MRgFUS, or UAE are appropriate for reproductive-age patients with symptomatic fibroids 4
• Hysteroscopic myomectomy specifically for pedunculated submucosal fibroids causing heavy bleeding 4

UAE Considerations for Adenomyosis

• UAE shows 65-82% long-term symptomatic relief (median follow-up 27.9 months) in patients with adenomyosis 4
• More recent studies report 73-88% symptom control with median follow-up of 24-65 months 4

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
• If bleeding persists and is unacceptable to the patient, counsel on alternative methods 4

Common Pitfalls to Avoid

• Do not rely on patient history alone to assess blood loss severity; pictorial blood loss assessment charts have 80% sensitivity and specificity 2
• Do not use cyclic progestogens as first-line in ovulatory women (only 20% reduction in blood loss) 8
• Do not prescribe progestins long-term (>6 months) due to meningioma risk 1
• Do not skip endometrial biopsy in women over 45 years, even with normal ultrasound 2
• Women of reproductive age on anticoagulants require careful counseling about increased menstrual bleeding risk, particularly with rivaroxaban (27% vs 8.3% prolonged bleeding compared to VKA) 4