Treatment
Treatment approaches for menorrhagia are based on the underlying medical cause and the onset, duration, and severity of the bleeding. Even the most thorough workup may fail to reveal a specific cause of the menorrhagia, especially in perimenopausal women. In these circumstances, the patient's desire for future childbearing, relevant comorbidities, and personal preferences largely guide the choice of intervention. A recent proliferation of management options has reduced unnecessary hysterectomies, avoiding surgical risk, financial cost, and permanent loss of fertility.
When a specific cause has been identified, treating the underlying disorder should eliminate the symptom. For instance, such bleeding disorders as von Willebrand disease require treatment with agents to prevent future bleeding (e.g., desmopressin). Abnormal thyroid function can usually be medically corrected, as can cervical infections or iatrogenic menorrhagia. Fibroids can be managed operatively via hysteroscopy, laparoscopic or abdominal myomectomy, or hysterectomy, depending on the extent of the lesions and the patient's surgical risk factors and desire for future childbearing. Such surgical alternatives as uterine artery embolization are gaining in popularity. If menorrhagia persists after apparently successful treatment for the underlying condition, additional causes should be investigated.
Women experiencing acute menorrhagia will need careful assessment of their hemodynamic stability and quick intervention to regulate bleeding. High-dose oral estrogen therapy with combined OCs or an estradiol formulation remains the mainstay of acute treatment (although some patients may require hospitalization for IV medications or dilation & curettage). Once stabilized, these patients will likely require long-term preventive therapy.
Nonsteroidal anti-inflammatory agents (NSAIDs) can serve as a useful adjunct treatment for menorrhagia, helping to relieve cramping as well as inducing vasoconstriction to reduce blood flow. Treatment options include ibuprofen 200-400 mg every four to six hours, mefenamic acid 500 mg as a loading dose followed by 250 mg every six hours, and naproxen 275 mg every eight hours. Studies show that effective NSAID use can result in a reduction in menstrual bleeding of 25%-35%.
Anemia from menstrual blood loss should be corrected concurrently with treatment of menorrhagia. Dietary iron sources, multivitamins, or ferrous sulfate may be advisable, depending on the extent of the deficiency. A very small percentage of women with menorrhagia will have anemia severe enough to require transfusion.
Prevention of future bleeding episodes is often best accomplished through ongoing hormonal treatment. Combined OCs containing estrogen and progestin can help to control menorrhagia, reducing bleeding by up to 60%. Other delivery mechanisms for hormones, such as the vaginal contraceptive ring (etonogestrel/ethinyl estradiol [NuvaRing]) and the transdermal patch (norelgestromin/ethinyl estradiol [Ortho Evra]), can be used if preferred. Continuous dosing of active pills or NuvaRing to eliminate withdrawal bleeding can be especially helpful for women with a history of menorrhagia, particularly those with concomitant anemia. Women with high BP, heart disease, or other risk factors for blood clots should avoid combined OCs. Other medical contraindications (e.g., a history of breast cancer) exist and should be reviewed prior to prescribing these medications to any patient. The patch is not recommended for women who weigh more than 198 lb.
Progestins can effectively suppress the endometrium to prevent abnormal bleeding. Depot medroxyprogesterone acetate (DMPA) may be injected every three months. After one year on DMPA, 70% of women will be amenorrheic.10 Side effects include weight gain, mood changes, and hair loss. Oral progestins, such as medroxyprogesterone or norethindrone, may be given daily or for 10-14 days of a 28-day menstrual cycle.
Many studies have affirmed the use of the levonorgestrel-containing intrauterine system (LNG-IUS) for management of menorrhagia.11,12 By releasing 20 µg of progestin daily for five years, the LNG-IUS reduces overall blood loss by about 90% and induces amenorrhea or oligomenorrhea in a majority of women. Even women who have failed to respond to other medication regimens may benefit from use of the LNG-IUS. The LNG-IUS also serves as a highly effective (<1% annual failure rate) but reversible form of contraception and is currently FDA-approved for five years' use. Some studies also demonstrate a reduction in size of uterine fibroids with use of the LNG-IUS.13 Women at high risk for STI or with other medical conditions may not be candidates for an LNG-IUS.
Endometrial ablation was pioneered in the late 20th century as a highly effective alternative to hysterectomy for the treatment of menorrhagia. Loop or rollerball electrocautery, laser techniques, and thermal balloon ablation are popular alternatives and can usually be performed as outpatient surgery. While many women achieve symptom relief following ablation, up to 40% of patients will go on to require further intervention.14
The LNG-IUS has numerous advantages over endometrial ablation and hysterectomy, including relatively low cost, reversibility, and ease of application.15 The LNG-IUS may be inserted in the office by a trained health-care provider and does not require highly specialized surgical equipment or operating space. Additionally, all women who undergo hysterectomy and many who undergo ablation are unable to become pregnant following those procedures,while the LNG-IUS may preserve future fertility.
Hysterectomy remains the treatment of last resort for menorrhagia and, despite its 9% complication rate and high cost, provides permanent relief of menorrhagia symptoms.