What is the treatment plan for a patient with menorrhagia (heavy menstrual bleeding) and regular menstrual cycles (N92.0)?

Treatment Plan for Menorrhagia with Regular Cycles (N92.0)

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for menorrhagia with regular cycles, demonstrating superior efficacy in reducing menstrual blood loss and improving quality of life compared to all other medical therapies. 1

Initial Diagnostic Workup

Laboratory Studies

• Complete blood count (CBC) to assess for iron deficiency anemia, which affects 20-25% of women with menorrhagia 1
• Thyroid-stimulating hormone (TSH) to exclude thyroid dysfunction as an underlying cause 2
• Pregnancy test to rule out pregnancy-related bleeding 3
• Coagulation screening (PT/INR, aPTT, platelet count) particularly in adolescents or women with personal/family history of bleeding disorders, as 10-20% of women with menorrhagia have underlying coagulopathies 4
• Ferritin level to assess iron stores 1

Imaging Studies

• Transvaginal ultrasound as the primary imaging modality to identify structural abnormalities including fibroids, polyps, or adenomyosis 1, 5
• Sonohysterography or hysteroscopy if ultrasound suggests endometrial polyps or submucous fibroids, as standard ultrasound is insufficient for definitive diagnosis 5
• Endometrial biopsy in women over 40 years or with risk factors for endometrial hyperplasia/cancer 5

Screening for Sexually Transmitted Infections

• Test for STIs in reproductive-aged women before initiating treatment 3

First-Line Medical Treatment

Levonorgestrel-Releasing Intrauterine System (LNG-IUS)

This is the gold standard first-line treatment with efficacy comparable to endometrial ablation or hysterectomy. 1

• Approximately 50% of users develop amenorrhea or oligomenorrhea after 2 years 1
• Particularly beneficial in women with severe thrombocytopenia 1
• Should be offered when contraception is desired or acceptable 1

Alternative First-Line Options

Combined Oral Contraceptives (COCs)

• Monophasic formulations containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are preferred 3
• Regularize cycles and significantly reduce bleeding by inducing regular shedding of thinner endometrium 1, 3
• Additional benefits include improvement in acne and reduced risk of endometrial and ovarian cancers 3
• Contraindication: Assess thrombotic risk factors before prescribing, as COCs increase venous thromboembolism risk three to fourfold 3

Tranexamic Acid

• Non-hormonal antifibrinolytic agent reducing menstrual blood loss by 34-59% over 2-3 cycles 1
• Particularly effective in women with bleeding disorders or coagulopathies 1
• Contraindication: Active thromboembolic disease or history/risk of thrombosis 3

NSAIDs (Mefenamic Acid)

• Mefenamic acid 500mg three times daily for 5-7 days during bleeding episodes 1
• Reduces menstrual blood loss by 20-35% 1
• Suitable for women wishing to avoid hormonal treatment 1
• Less effective than LNG-IUS or tranexamic acid 5

Oral Progestins

• Norethindrone is useful, particularly in women with severe thrombocytopenia 1
• Critical limitation: Should not be used for more than 6 months due to risk of meningiomas 1
• Avoid depot medroxyprogesterone acetate (DMPA) in severe thrombocytopenia due to irregular bleeding and 11-13 week irreversibility 1, 6

Iron Supplementation for Anemia

Treatment Protocol

• Ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1
• Add ascorbic acid to improve iron absorption if response is insufficient 1
• Continue treatment for 3 months after correction of anemia to replenish iron stores 1

Management of Persistent Bleeding

Initial 3-6 Months

• Reassure patients that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and generally not harmful 3
• Add NSAIDs for 5-7 days during bleeding episodes to reduce blood flow acutely 3

If Bleeding Persists Beyond 6 Months

• Re-evaluate for underlying gynecological problems 3
• Consider hormone-free interval of 3-4 consecutive days for heavy bleeding in extended/continuous COC regimens (but not during first 21 days or more than once per month) 3
• Counsel on alternative contraceptive methods and offer another method if current treatment is unacceptable 3

Surgical Options (Second-Line)

Endometrial Ablation

• For women who have completed childbearing and failed medical management 6
• High satisfaction rate (>95%) in patients with menorrhagia 6

Hysteroscopic Myomectomy

• Treatment of choice for submucous pedunculated fibroids <5cm 6
• Shorter hospitalization and faster recovery compared to abdominal approach 6

Uterine Artery Embolization (UAE)

• Alternative to surgery with 81-100% clinical success rate 1
• 83% of women report symptom improvement at 3 months 1
• Important caveat: 20-25% risk of symptom recurrence at 5-7 years 1, 6

Hysterectomy

• Definitive treatment with 90% satisfaction at 2 years 6
• Should be considered last resort due to invasive nature and loss of fertility 6

Follow-Up Schedule

Short-Term Follow-Up

• Re-evaluate at 3-6 months after initiating treatment to assess efficacy 1
• Monitor blood pressure at follow-up visits for patients on COCs 3
• Assess satisfaction with treatment method and any health status changes 3

Long-Term Monitoring

• Monitor hemoglobin and erythrocyte indices every 3 months for 1 year, then annually 1
• Further investigation only necessary if hemoglobin and MCV cannot be maintained within normal ranges 1

Patient Education

Bleeding Patterns

• Inform patients that unscheduled spotting or bleeding is common during first 3-6 months of hormonal therapy 3
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 3

When to Seek Care

• Return for side effects or concerns 3
• Report excessive postpartum bleeding immediately if pregnancy occurs 4

Medication-Specific Counseling

• COCs: Warn about increased menstrual flow risk if alteplase needed for stroke 7
• LNG-IUS: Counsel on high likelihood of amenorrhea/oligomenorrhea after 2 years 1

Health Promotion and Disease Prevention

Contraception Counseling

• LNG-IUS and COCs provide dual benefit of menorrhagia treatment and contraception 1, 3
• Discuss contraceptive needs and preferences when selecting treatment 1

Cancer Risk Reduction

• COCs reduce risk of endometrial and ovarian cancers 3
• Appropriate screening with Pap test and endometrial biopsy (when indicated) for cancer prevention 2, 5

Anemia Prevention

• Maintain iron supplementation until stores are replenished 1
• Annual monitoring prevents recurrent iron deficiency 1

Cardiovascular Risk Assessment

• Screen for thrombotic risk factors before prescribing COCs 3
• Monitor blood pressure in patients on hormonal therapy 3

Referrals

Gynecology Referral

• Structural abnormalities requiring surgical intervention (fibroids, polyps) 1
• Failed medical management requiring endometrial ablation or hysterectomy 6
• Abnormal endometrial biopsy results 5

Hematology Referral

• Confirmed or suspected bleeding disorder 4
• Severe thrombocytopenia requiring specialized management 1

Interventional Radiology Referral

• Consideration of uterine artery embolization 1, 6