What are the treatment options for a woman with menorrhagia (heavy menstrual bleeding)?

Medical Management of Menorrhagia

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line treatment for menorrhagia, reducing menstrual bleeding significantly and improving quality of life, with approximately 50% of users achieving amenorrhea or oligomenorrhea by 2 years of use. 1, 2

First-Line Medical Therapies

Levonorgestrel-Releasing Intrauterine System (LNG-IUS)

• The LNG-IUS is the gold standard for medical management when contraception is desired or acceptable, with efficacy comparable to endometrial ablation or hysterectomy. 1
• Particularly beneficial in women with severe thrombocytopenia, as it effectively treats menorrhagia even in this high-risk population 1
• Unscheduled spotting or light bleeding is expected during the first 3-6 months but generally decreases with continued use 2
• Over time, bleeding generally decreases, with many women experiencing only light menstrual bleeding or amenorrhea 2

Combined Oral Contraceptives

• Effective alternative for regularizing cycles and significantly reducing bleeding, particularly when contraception is also desired 1, 2
• Monophasic formulations containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are recommended 3
• Reduce menstrual blood loss by inducing regular shedding of a thinner endometrium 3
• Assess thrombotic risk factors before prescribing, as they increase venous thromboembolism risk three to fourfold 3

Tranexamic Acid

• Non-hormonal antifibrinolytic agent that reduces menstrual blood loss by 34-59% over 2-3 cycles 1
• Particularly effective in women with bleeding disorders or coagulopathies 1
• Appropriate when hormonal treatment is contraindicated or immediate pregnancy is desired 3
• Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 3, 2

Second-Line Medical Therapies

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Mefenamic acid 500mg three times daily reduces menstrual blood loss by 20-35% 1
• Suitable for short-term use (5-7 days) during bleeding episodes 1
• Appropriate for women who wish to avoid hormonal treatment 1
• Can be added as adjunctive therapy for 5-7 days during bleeding episodes if first-line treatments are insufficient 3

Progestins

• Useful particularly in women with severe thrombocytopenia 1
• Should not be used for more than 6 months due to risk of meningiomas 1
• Avoid depot medroxyprogesterone acetate (DMPA) in acute menorrhagia due to irregular bleeding and 11-13 week irreversibility 1, 4
• DMPA is not recommended for dysfunctional uterine bleeding due to prolonged action and difficulty predicting withdrawal bleeding 4

Special Populations and Considerations

Women with Coagulation Disorders

• Screen for bleeding disorders, particularly in adolescents or women with severe thrombocytopenia 1
• LNG-IUS remains first-line even in severe thrombocytopenia 1
• Tranexamic acid is particularly effective but contraindicated if active thrombosis risk exists 1, 3

Management of Persistent Bleeding

• Reassure patients that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and generally not harmful 3
• Re-evaluate for underlying gynecological problems (LNG-IUS displacement, STDs, pregnancy, polyps, fibroids) if bleeding persists beyond initial months 2, 3
• Consider adding NSAIDs for 5-7 days during bleeding episodes to reduce blood flow acutely 3
• If bleeding persists despite treatment and is unacceptable to the patient, counsel on alternative contraceptive methods 2, 3

Diagnostic Evaluation Before Treatment

• Evaluate for iron deficiency anemia, as menorrhagia affects 20-25% of reproductive-age women and is the most common cause of iron deficiency 1
• Search for uterine pathology (fibroids, polyps, adenomyosis) using ultrasound or MRI 1
• Exclude pregnancy, even in perimenopausal women, before initiating treatment 3
• Exclude sexually transmitted infections, particularly in reproductive-aged women 3
• Screen for coagulation disorders in appropriate populations 1

Anemia Management

• Supplement with ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1
• Consider ascorbic acid to improve iron absorption in cases of insufficient response 1
• Continue treatment for three months after correction of anemia to replenish iron stores 1
• Monitor hemoglobin and erythrocyte indices every 3 months for 1 year, then annually 1

Surgical Options When Medical Management Fails

Uterine Artery Embolization (UAE)

• Clinical success rate of 81-100% with symptom improvement in 83% of women at 3 months 1
• Risk of symptom recurrence in 20-25% of women at 5-7 years 1
• Alternative to surgery for women who have failed medical management 1

Endometrial Ablation

• Option for women who do not desire future pregnancy, with high satisfaction (>95%) 5
• LNG-IUS efficacy is comparable to endometrial ablation 1

Hysterectomy

• Definitive treatment with 90% satisfaction at 2 years 5
• Should be considered as last option due to invasive nature and loss of fertility 5

Common Pitfalls to Avoid

• Do not use DMPA for acute menorrhagia management due to irregular bleeding patterns and prolonged irreversibility 1, 4
• Do not prescribe combined oral contraceptives without assessing thrombotic risk factors 3
• Do not use progestins for more than 6 months due to meningioma risk 1
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates and improves adherence 3
• Re-evaluate at 3-6 months after treatment initiation to assess efficacy 1