What are the treatment options for a woman experiencing excessive uterine bleeding during menstruation, also known as menorrhagia?

Treatment of Excessive Uterine Bleeding During Menstruation (Menorrhagia)

Start with medical management using a levonorgestrel-releasing intrauterine device (IUD), tranexamic acid, NSAIDs, or combined oral contraceptives before considering surgical options, as these therapies effectively reduce menstrual blood loss by 20-60% and significantly improve quality of life. 1, 2, 3

Initial Diagnostic Evaluation

Before initiating treatment, perform targeted evaluation to identify structural causes and exclude malignancy:

• Obtain pregnancy test, complete blood count to assess for anemia, thyroid-stimulating hormone, and prolactin levels to rule out pregnancy and identify endocrine causes of bleeding 4, 5

• Perform combined transabdominal and transvaginal ultrasound with Doppler as the initial imaging study to evaluate endometrial thickness and identify structural abnormalities including fibroids, polyps, and adenomyosis 4

• Endometrial biopsy is essential in perimenopausal women (typically over age 40) with heavy menstrual bleeding to exclude endometrial cancer or hyperplasia, even when imaging appears normal, due to significantly elevated malignancy risk in this age group 4, 3

• If ultrasound is inconclusive or the endometrium cannot be fully visualized, proceed to MRI of the pelvis without and with contrast for superior endometrial visualization 4

• Sonohysterography should be performed if a polyp is suspected on initial ultrasound, allowing better visualization of intracavitary lesions 4, 3

First-Line Medical Management

Medical therapy should be attempted before any surgical intervention:

Hormonal Options

• Levonorgestrel-releasing intrauterine device (IUD) is the most effective medical treatment, with efficacy comparable to endometrial ablation or hysterectomy, and should be strongly considered as first-line therapy for women desiring uterus preservation 1, 3, 6, 7

• Combined oral contraceptives effectively reduce menstrual bleeding and are appropriate first-line options, particularly in younger women who also desire contraception 1, 2

• Progestin-only contraception reduces heavy menstrual bleeding, though the levonorgestrel IUD is clinically favored due to local mechanism of action, lower systemic hormone levels, and long duration after placement 1

• Avoid cyclic progestogens in ovulating women, as they do not significantly reduce menstrual bleeding 3

Non-Hormonal Options

• Tranexamic acid reduces menstrual blood loss by 20-60% and is an effective non-hormonal alternative, particularly useful in patients with fibroids or those who cannot use hormonal therapy 1, 3, 6

• NSAIDs (such as ibuprofen 400 mg every 4-6 hours or mefenamic acid) reduce menstrual blood loss by 20-60% through prostaglandin synthetase inhibition 8, 3, 6, 5

  • Ibuprofen dosing: 400 mg every 4-6 hours as necessary, beginning with earliest onset of bleeding 8
  • NSAIDs are particularly effective when started at the onset of menstruation 8

• GnRH antagonists (elagolix, linzagolix, relugolix) effectively reduce bleeding symptoms and can significantly reduce fibroid volume when fibroids are present, though symptoms return after discontinuation 1, 2

Surgical Management

Consider surgical options when medical management fails, is contraindicated, or the patient desires definitive treatment:

Minimally Invasive Options

• Endometrial ablation is appropriate for women who have completed childbearing and failed medical management, with satisfaction rates approaching those of hysterectomy while preserving the uterus 6, 7

• Uterine artery embolization (UAE) is effective for patients with fibroids and adenomyosis who desire uterus-preserving therapy, with 94% short-term symptom improvement and 85% long-term improvement, though 7% require subsequent hysterectomy for persistent symptoms 1

• Hysteroscopic myomectomy or laparoscopic myomectomy may be appropriate for submucosal or intramural fibroids in women desiring fertility preservation 1

Definitive Treatment

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and eliminates recurrence risk, accounting for three-quarters of fibroid treatment in the United States 1, 2

• Choose the least invasive surgical route (vaginal > laparoscopic/robotic > abdominal) based on uterine size and surgical expertise, as vaginal and laparoscopic approaches are associated with shorter hospital stays, faster recovery, and lower complication rates compared to abdominal hysterectomy 1

• Hysterectomy provides significantly better health-related quality-of-life outcomes compared to other therapies and should be considered when medical management fails or is contraindicated 2, 7

Treatment Algorithm by Clinical Scenario

Reproductive-Age Women Desiring Fertility Preservation

• Start with tranexamic acid or NSAIDs for symptomatic relief 3, 6
• If structural abnormalities (fibroids, polyps) are identified, consider hysteroscopic or laparoscopic resection 1
• Avoid levonorgestrel IUD if pregnancy is desired in the near term 7

Reproductive-Age Women Not Desiring Future Fertility

• Levonorgestrel-releasing IUD is first-line therapy due to superior efficacy and long-term tolerability 1, 3, 7
• Alternative first-line options include combined oral contraceptives, tranexamic acid, or NSAIDs 1, 2, 3
• If medical management fails after adequate trial (typically 3-6 months), proceed to endometrial ablation or hysterectomy based on patient preference 2, 7

Perimenopausal Women

• Endometrial biopsy is mandatory to exclude malignancy before initiating treatment 4, 3
• Medical management with levonorgestrel IUD, combined oral contraceptives, or tranexamic acid is appropriate if malignancy is excluded 1, 2
• Hysterectomy is usually appropriate for symptomatic perimenopausal women who fail medical management, providing definitive resolution 2

Important Caveats and Pitfalls

• Never assume bleeding in perimenopausal women is simply due to perimenopause—endometrial cancer risk increases significantly with age, and thorough evaluation including endometrial sampling is essential 4

• Adenomyosis frequently coexists with fibroids (common in women in their 40s) and may affect treatment success; MRI is more sensitive than ultrasound for diagnosis 1, 2

• Coagulopathies should be considered in women with heavy bleeding since menarche or family history of bleeding disorders, though routine testing of all women is unnecessary 5, 7

• Women on anticoagulation (particularly NOACs like rivaroxaban) have increased risk of abnormal uterine bleeding (27% vs 8.3% with warfarin), requiring careful counseling and monitoring, especially during the first cycles after initiation 1

• Medical menopause with GnRH agonists/antagonists is temporary—symptoms return after discontinuation, making this appropriate only for short-term management or preoperative preparation 2

• Endometrial biopsy is essential even with normal imaging in perimenopausal women, as imaging alone is insufficient to exclude malignancy 4