What is the best approach for a patient with menorrhagia?

Management of Menorrhagia

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for menorrhagia, reducing menstrual blood loss by up to 96% after 12 months, with approximately 50% of users achieving amenorrhea or oligomenorrhea after 2 years. 1

Immediate Diagnostic Priorities

Mandatory Initial Assessment

• Screen for iron deficiency anemia immediately, as menorrhagia affects 20-25% of women of reproductive age and is the most common cause of iron deficiency in this population 2, 3
• Obtain complete blood count (hemoglobin and MCV) to assess severity and guide treatment urgency 3
• Perform pelvic examination to identify structural abnormalities 4
• Rule out pregnancy first before initiating any treatment 5

Structural Evaluation

• Perform transvaginal ultrasound as the primary imaging modality to detect fibroids (most common in women <40 years), polyps (most common >40 years), and adenomyosis 3, 4
• Consider sonohysterography or hysteroscopy if ultrasound is insufficient for diagnosing endometrial polyps or submucosal fibroids 4
• Endometrial sampling is essential in women >45 years or those with risk factors for endometrial hyperplasia/cancer 4

Exclude Coagulation Disorders

• Screen for bleeding disorders, particularly in adolescents or women with severe thrombocytopenia 6, 3
• Consider thyroid function testing (TSH) if clinical suspicion exists 5

Treatment Algorithm

First-Line Medical Management

When contraception is desired or acceptable:

• LNG-IUS is the gold standard, with efficacy comparable to endometrial ablation or hysterectomy 6, 1, 4
• The LNG-IUS is particularly beneficial in women with severe thrombocytopenia, as it can effectively treat menorrhagia even in this high-risk population 6
• Combined oral contraceptives are an effective alternative, regularizing cycles and significantly reducing bleeding compared to NSAIDs, antifibrinolytics, or oral progestins 6, 3, 1
• Provide thorough counseling about expected bleeding patterns with hormonal treatments to prevent non-adherence 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 2, 3, 1, 4
• Tranexamic acid is particularly effective in women with bleeding disorders or coagulopathies 3, 1
• NSAIDs (mefenamic acid 500mg three times daily or ibuprofen) for 5-7 days during bleeding episodes reduce blood loss by 20-35% 2, 3, 4, 7
• NSAIDs are less effective than tranexamic acid or hormonal options but suitable for women refusing hormonal treatment 3

Special Population Considerations

Adolescents:

• Tranexamic acid 1.5-2g three times daily during menstruation is first-line therapy 2
• Combined oral contraceptives are effective for cycle regulation 2
• Oral progestins (norethindrone) may be used in severe thrombocytopenia but should not be used for more than 6 months due to meningioma risk 2, 1

Women with severe thrombocytopenia:

• LNG-IUS is particularly useful and safe 6
• Avoid depot medroxyprogesterone acetate (DMPA) due to irregular bleeding and 11-13 week irreversibility 3

Critical Pitfall to Avoid

Cyclic oral progestins do NOT significantly reduce menstrual bleeding in ovulating women and should not be used as primary treatment 4. Additionally, never prescribe progestins for more than 6 months due to meningioma risk 2, 1.

Anemia Management Protocol

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

Surgical Options When Medical Management Fails

Minimally Invasive 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 3, 1
• However, UAE carries a 20-25% risk of symptom recurrence at 5-7 years 3

Hysterectomy

• Reserved as treatment of last resort when all other options have failed 5

Follow-Up Protocol

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

Key Clinical Pearls

• Start with medical therapy and evaluate before considering surgical interventions 4
• The patient's subjective assessment of blood loss does not generally reflect the true amount; objective measures (anemia, iron deficiency) are more reliable 4, 8
• Approximately 50% of women with menorrhagia have identifiable uterine pathology (fibroids, polyps, adenomyosis), while the other 50% have dysfunctional uterine bleeding 4, 7
• Drug treatment should be used and evaluated before surgical interventions are considered 4