What is the appropriate management 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

Initial Diagnostic Evaluation

History and Assessment

• Patient-reported blood loss is unreliable; pictorial blood loss assessment charts should be used, which have 80% sensitivity and specificity for detecting menorrhagia 1
• Screen for bleeding disorders (particularly von Willebrand disease) in adolescents and women with severe thrombocytopenia, as 10-20% of women with objectively documented menorrhagia have inherited bleeding disorders 2, 3
• Assess for thyroid dysfunction, hyperprolactinemia, polycystic ovary syndrome, and medication use (antipsychotics, antiepileptics) as causes of anovulatory bleeding 4

Laboratory Testing

• Complete blood count to assess for anemia (menorrhagia is the most common cause of iron deficiency in 20-25% of reproductive-age women) 2
• Thyroid-stimulating hormone (TSH) level 4, 5
• Coagulation studies if bleeding disorder suspected (PT/INR, aPTT, von Willebrand panel including factor VIII, vWF antigen, and vWF functional assay) 3
• Pregnancy test to exclude pregnancy-related bleeding 5

Imaging

• Transvaginal ultrasound is the first-line imaging modality to evaluate for structural causes (fibroids, polyps, adenomyosis) 1
• Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for detecting intracavitary pathology 1

Endometrial Sampling

• Women over 45 years require endometrial biopsy regardless of ultrasound findings due to increased risk of endometrial pathology 1
• Women under 35 years with risk factors for endometrial cancer (chronic anovulation, obesity, diabetes) should undergo endometrial biopsy 4
• Women with excessive bleeding unresponsive to medical therapy require endometrial biopsy 4

Medical Management Algorithm

First-Line Treatment: LNG-IUS

• The LNG-IUS is the gold standard, with efficacy comparable to endometrial ablation or hysterectomy 2
• Reduces menstrual blood loss by up to 96% after 12 months 1
• Particularly beneficial in women with severe thrombocytopenia or bleeding disorders 2
• Approximately 50% of users achieve amenorrhea or oligomenorrhea after 2 years 1, 2

Alternative Hormonal Options

• Combined oral contraceptives regularize cycles and significantly reduce bleeding, suitable when contraception is also desired 1, 2, 4
• Oral progestins (norethindrone) for 21 days per month are effective, but should not be used for more than 6 months due to risk of meningiomas 2
• Depot medroxyprogesterone acetate (DMPA) may be used in women with severe thrombocytopenia, but avoid due to irregular bleeding and 11-13 week irreversibility 2

Non-Hormonal Medical Options

• Tranexamic acid 1.5-2g three times daily during menstruation reduces blood loss by 34-59% over 2-3 cycles 1, 6
• Particularly effective in women with bleeding disorders or coagulopathies who wish to avoid hormonal treatment 2
• NSAIDs (mefenamic acid 500mg three times daily for 5-7 days during bleeding) reduce menstrual blood loss by 20-35%, but have limited efficacy compared to other options 2, 6

Anemia Management

• 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
• Ascorbic acid enhances iron absorption and should be considered when response is poor 1, 2
• Monitor hemoglobin and mean corpuscular volume (MCV) every 3 months for 1 year, then annually 1, 2

Surgical Management

Indications for Surgical Intervention

• Medical management failure after 3-6 months of appropriate therapy 1
• Clear structural causes identified (submucosal fibroids, polyps) 4
• Patient preference when fertility preservation not desired 4

Surgical Options

• Endometrial ablation: satisfaction rates exceeding 95%, but 20-25% risk of symptom recurrence at 5-7 years 1, 2
• Uterine artery embolization (UAE): 81-100% clinical success rate, with 83% of women reporting symptom improvement at 3 months 1, 2
  • Pre-procedural workup includes cross-sectional imaging, Pap smear, and endometrial biopsy if menometrorrhagia present 1
• Hysterectomy: most definitive treatment, reserved for failed medical/conservative surgical management 4, 7

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
• Further investigation only necessary if hemoglobin and MCV cannot be maintained within normal ranges 2

Critical Pitfalls to Avoid

• Do not use cyclic progestogens in ovulatory women—they do not significantly reduce menstrual bleeding in women who ovulate 6
• Do not rely on patient-reported blood loss alone—use validated pictorial assessment charts 1
• Do not defer endometrial biopsy in women over 45 years, even with normal ultrasound findings 1
• Do not miss bleeding disorders—screen appropriately, especially in adolescents and those with family history 3
• Do not use DMPA as first-line in most cases due to irregular bleeding and prolonged irreversibility 2