Approach to Managing Heavy Menstrual Bleeding (Menorrhagia)
Initial Diagnostic Evaluation
The first priority is to exclude pregnancy and identify life-threatening bleeding requiring urgent intervention. 1
Immediate Assessment
- Test for pregnancy (beta-hCG) in all reproductive-age women before proceeding with any evaluation or treatment 1, 2
- Assess hemodynamic stability: bleeding saturating a large pad or tampon hourly for ≥4 hours warrants urgent evaluation 1
- Measure hemoglobin/hematocrit to assess for anemia and severity 3, 4
Key History Elements
- Quantify bleeding severity: ask specifically about clots ≥1 inch diameter, "flooding" (changing pad/tampon more than hourly), and prolonged menses (>7 days) 3
- Personal and family bleeding history: easy bruising, epistaxis, postpartum hemorrhage, bleeding with dental procedures, or family history of bleeding disorders strongly suggests underlying coagulopathy 3
- Medication review: anticoagulants, antiplatelet agents (aspirin, clopidogrel), NSAIDs, and hormonal contraceptives 1, 3
- Age and fertility desires: critical for treatment selection 5, 6
Physical Examination and Imaging
- Perform pelvic examination to assess for uterine size, masses, or anatomical abnormalities 4
- Transvaginal ultrasound (or transabdominal if not sexually active) is the primary imaging modality to evaluate for fibroids, polyps, adenomyosis, and endometrial thickness 2, 4
- Sonohysterography or hysteroscopy provides superior diagnosis of endometrial polyps and submucosal fibroids compared to ultrasound alone 4
Laboratory Workup
- Thyroid function (TSH, free T4) and prolactin level: these are the most common endocrine causes of menstrual irregularity 2, 5
- Coagulation studies if personal/family bleeding history is positive or if flooding/prolonged menses present: consider von Willebrand disease screening, platelet count, PT/PTT 3
- Ferritin level: low ferritin predicts clinically significant blood loss 3
Treatment Algorithm
First-Line Medical Management
For most women with heavy menstrual bleeding without desire for immediate pregnancy, the levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is the most effective medical therapy, reducing menstrual blood loss by 71-95%. 1, 4
LNG-IUD (Levonorgestrel 20 μg/day)
- Efficacy comparable to endometrial ablation or hysterectomy for reducing menstrual blood loss 1, 4
- Particularly beneficial in specific populations: women with severe thrombocytopenia, those on antiplatelet therapy after cardiac events, and women with endometriosis 1
- Main effect is local at endometrial level with minimal systemic progesterone absorption 1
- Also provides contraception 1
Alternative First-Line Options (if LNG-IUD contraindicated or declined)
Tranexamic acid reduces menstrual blood loss by 40-60% 4
- Avoid in women with history of thrombosis or cardiovascular disease (MI, stroke, SCAD) due to thrombotic risk 1
NSAIDs (mefenamic acid 500 mg three times daily or ibuprofen 400 mg every 4-6 hours) reduce menstrual blood loss by 20-30% 1, 7, 8, 4
- Use for 5-7 days during menstruation only 1, 7
- Avoid in women with cardiovascular disease (particularly SCAD) due to MI association 1
Combined oral contraceptives (COCs) with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1, 2, 4
- Effective for cycle regulation and reducing blood loss 1, 4
- Contraindicated in women with cardiovascular disease, thrombotic risk, migraine with aura, or age >35 with smoking 1
Second-Line Medical Management
If first-line therapies fail or are contraindicated:
Cyclic oral progestin (progesterone 400 mg daily for 10 days per cycle for secondary amenorrhea; 200 mg daily for 12 days per 28-day cycle for endometrial protection) 9
- Reduces bleeding by 87% in women with anovulatory bleeding 1
- Note: cyclic progestogens do NOT significantly reduce bleeding in ovulatory women 4
- Take at bedtime due to drowsiness and dizziness 9
High-dose progestin (oral or injectable) for short-term hemodynamic instability 1
Surgical Management
Consider surgical options when medical management fails, is contraindicated, or patient preference:
Endometrial ablation (second-generation techniques: thermal balloon, microwave, radiofrequency) 1
- Long-term efficacy superior to oral medical treatment 1
- Particularly appropriate for women who wish to avoid hormones (e.g., post-SCAD patients) 1
Hysterectomy remains definitive treatment for refractory cases 4
Critical Pitfalls to Avoid
- Never assume "dysfunctional uterine bleeding" without excluding structural pathology (fibroids, polyps, hyperplasia, malignancy), especially if bleeding persists >3 years post-menarche 2, 10
- Do not use tranexamic acid or NSAIDs in women with cardiovascular disease (SCAD, MI, stroke history) due to thrombotic risk 1
- Do not prescribe cyclic progestogens to ovulatory women expecting significant reduction in menstrual blood loss—they are ineffective in this population 4
- Always exclude pregnancy before initiating any treatment 1, 2
- Refer to hematology if flooding, prolonged menses, or personal/family bleeding history present—90% of women with underlying bleeding disorders experience heavy menstrual bleeding 3
- Do not use combined oral contraceptives in women with migraine with aura, cardiovascular disease, or thrombotic risk factors 1
Special Populations
Women on Antiplatelet Therapy (Post-SCAD, Post-PCI)
- Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate 1
- LNG-IUD (20 μg/day) is preferred as it avoids systemic hormonal effects while providing local endometrial suppression 1
- Avoid NSAIDs and tranexamic acid due to MI/thrombosis risk 1
- Consider endometrial ablation if medical management fails 1
Women with Bleeding Disorders
- LNG-IUD is particularly useful in women with severe thrombocytopenia at risk for spontaneous bleeding 1
- Hemostatic therapy may be life-saving when correcting an underlying coagulopathy 3