Menorrhagia (Heavy Menstrual Bleeding) - Treatment

Definition & Classification

• PALM (structural): Polyps, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
• COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic, Not otherwise classified

Initial Workup Before Treatment

• Detailed history and pelvic examination
• Pregnancy test, CBC, thyroid function, prolactin, cervical screening
• Pelvic ultrasound
• Endometrial biopsy: mandatory in women ≥45 years or younger with obesity, ovulatory dysfunction, persistent/refractory AUB, or familial cancer risk
• Screen for coagulopathy if: bleeding since menarche, family history of coagulopathy, or systemic bleeding signs

NON-HORMONAL MEDICAL TREATMENT

1. NSAIDs

• Mechanism: inhibit cyclooxygenase in the arachidonic acid cascade, alter prostaglandin F2α/E2 ratio toward vasoconstriction, increase thromboxane A2
• Reduce blood loss by 20-50% in ovulatory dysfunction; less useful in leiomyoma-related HMB
• Start on day 1 of menses, continue until bleeding stops
• Options:
  • Mefenamic acid 500 mg TDS
  • Naproxen 500 mg BD
  • Ibuprofen 400 mg every 6 hours
• Side effects: mainly GI upset; mild profile overall

2. Tranexamic Acid

• Synthetic antifibrinolytic agent
• Dose: 1.3 g three times daily for 3-5 days during menses
• Significantly reduces menstrual blood loss vs placebo (p <0.001) even in women with fibroids
• Side effects: headache (55%), nausea (15%)
• Compared favorably with hormone therapy and NSAIDs for quality of life improvement

HORMONAL MEDICAL TREATMENT

3. Combined Oral Contraceptive Pills (COCPs)

• Reduce heavy menstrual bleeding by 35-69% and dysmenorrhea by ~50%
• First-line choice for adolescents and women who also desire contraception
• Preferred in younger, healthy women where bleeding is anovulatory and endometrial pathology is low concern
• Contraindications: smoking, liver disease, thromboembolism/cardiovascular history, breast cancer, unexplained vaginal bleeding

4. Progestin-Only Therapy

• Mechanism: decreases estrogen receptors, stabilizes the endometrium
• Preferred when:
  • Contraindication to estrogen
  • Older/perimenopausal or obese patients
  • Concern for endometrial pathology or hyperplasia
• ACOG regimen: medroxyprogesterone acetate 20 mg TDS x 7 days (acute), or 10 mg daily x 10 days
• Options: oral progestin pills, depot medroxyprogesterone acetate (DMPA), progestin-only pills

5. Levonorgestrel-Releasing IUD (LNG-IUS, e.g. Mirena)

• Reduces HMB by 71-95% - the most effective medical option
• Superior to COCPs (35-69%) and NSAIDs (10-52%)
• Most women develop amenorrhea, particularly with the 52 mg device
• Irregular spotting is common in the first 4-6 months
• Ideal for women not desiring fertility who also need contraception

6. GnRH Agonists (e.g. leuprolide, nafarelin)

• Induce amenorrhea by producing a hypoestrogenic state
• Reduce fibroid volume by ~30% and uterine volume by ~35% over 6 months
• 37/38 women had resolution of HMB by 6 months
• Not for long-term use (>6 months) due to bone loss and menopausal side effects (hot flushes 78%, vaginal dryness 32%, headaches 55%, arthralgia, insomnia, depression)
• Uses:
  • Bridge to surgery (fibroid downsizing preoperatively)
  • Perimenopausal women awaiting natural menopause
  • Add-back low-dose estrogen/progestin can reduce side effects

7. GnRH Antagonists (e.g. elagolix, relugolix, ganirelix)

• Immediate GnRH suppression (no initial flare unlike agonists)
• Reduce fibroid volume ~29% within 3 weeks
• A 2025 meta-analysis (PMID 39821450) confirmed GnRH antagonists are efficacious for fibroid-related uterine bleeding
• Oral formulations (elagolix, relugolix) offer convenience for pre-surgical treatment

8. Progesterone Receptor Modulators

• Mifepristone: reduces uterine size ~48% over 6 months; risk of endometrial hyperplasia (28% in one systematic review) requires endometrial monitoring
• Ulipristal acetate (UPA): selective progesterone receptor modulator; was used for fibroid-related HMB (regulatory caution in some regions due to rare liver toxicity)

SURGICAL TREATMENT

9. Endometrial Ablation

• Destroys the endometrial lining; induces hypomenorrhea or amenorrhea
• Ideal candidate criteria:
  • Menorrhagia unresponsive to medical therapy
  • No desire for future fertility
  • No endometrial pathology (negative biopsy required)
• Methods: resectoscopic, thermal balloon, microwave, radiofrequency
• A 2026 meta-analysis (PMID 41813372) showed microwave ablation has both short- and long-term effectiveness for menorrhagia from adenomyosis and myoma
• Cochrane evidence shows endometrial ablation is an effective alternative to hysterectomy

10. Hysteroscopy

• Diagnostic and therapeutic
• Resects polyps, submucous fibroids (myomas), and samples endometrium
• Especially effective for structural causes (PALM group)

11. Myomectomy

• Surgical removal of fibroids while preserving the uterus
• Suitable for women with symptomatic leiomyomas who desire future fertility
• Approaches: hysteroscopic (submucous), laparoscopic (intramural/subserosal), open

12. Uterine Artery Embolization (UAE)

• Effective non-surgical option for fibroid-related HMB
• Interrupts blood supply to fibroids causing ischemic infarction
• Preserves the uterus; recovery faster than surgery

13. Hysterectomy

• Definitive cure - reserved for:
  • Failed medical and conservative surgical management
  • Women who have completed childbearing
  • Underlying malignancy
  • Severe anemia from refractory bleeding
• Most cost-effective to exhaust outpatient/medical options first

TREATMENT SUMMARY BY SCENARIO

TREATMENT EFFECTIVENESS COMPARISON