I. Defined as > 80-90ml/period; only 2/5 of women who c/o excessive bleeding actually exceed this amount
- Bleeding elsewhere?
- Strictly limited to part of each month?
- Always r/o PREGNANCY!
- CBC to r/o anemia which occurs in 2/3 of women, and thrombocytopenia
- Consider endometrial bx esp. if there is intermenstrual bleeding
- Consider u/s to look for fibroids
IV. Tx: start with medical; surgery rarely necessary
- Initial tx of choice
- Inhibit prostaglandin synthesis and cause uterine vasoconstriction
- Also help with dysmenorrhea which is common in these women
- Mefanamic acid (Ponstel) 500 TID has been studies most, but ibuprofen 400 QID, naproxen 375 BID, indocin 25 TID also found to be effective at reducing blood loss
- OC's (if pt doesn't want to get pregnant)
- Levonorgestrel-containing IUD's
- Control bleeding (BMJ 316:1122, 1998--JW) but may be ass'd with higher risk ectopic preg. than other IUD's
- 232 women with menorrhagia (mean age 43yo) randomized to levonorgestrel-releasing IUD vs. hysterectomy; no sig. diff. in improvements in health-related quality of life at 5y (JAMA 291:1456, 2004--JW)
- More effective at reducing volume of menorrhagia than an NSAID (mefemanic-acid) in one 6mo randomized trial (Br. J. Obs. Gyn. 112:1121, 2005--JW)
In a study in 162 women with menorrhagia randomized to levonorgestrel-releasing IUD vs. monthly oral medroxyprogesterone acetate 10mg/d x 10d; over 6mos, the IUD group had sig. higher incidence of > 50% reduction in blood loss (80% vs. 30%) (Obs. Gyn. 116:625, 2010-JW)
- Cyclic progesterone, e.g. Provera 10-20mg QD for days 16-25 of each month (doesn't prevent pregnancy!)-not used much anymore
- GnRH agonists, e.g. Lupron, to reduce estrogen levels; however, expensive and prolonged use may cause osteoporosis
- Danazol (a synthetic androgen with antiestrogenic properties)-reduces blood flow more than NSAIDs but expensive and more side f/x (acne, spotting, hot flashes, hirsutism, etc.)
- Tranexamic acid (Lysteda)
- An oral fibrinolysis inhibitor
- Effective at 1300mg TID (for up to 5d during menses; adjust dose in renal impairment) for controlling bleeding in pts with menorrhagia
- Associated with headaches,sinus pain, myalgias, arthralgias, anemia, and fatigue.
- Also, theoretical possibility of increased risk for thrombosis.
- In a study in 63 premenopausal women 30-50yo with menorrhagia not adequately controlled on cycloc medroxyprogesterone acetate randomized to hysterectomy vs. medical therapy (combined OCPs + a prostaglandin inhibitor); at 6mos, surgery group had sig. greter improvements in pelvic pain, breast pain, and urinary urgency; at 2y, surgery group had sig. less hot flashes and incomplete bladder emptying (Obs. Gyn. 103:824, 2004--AFP)
- D & C-only temporary solution
- Endometrial ablation (variety of techniques)
- Usually prevents subsequent pregnancy
- 20% go on to have hysterectomy
- Radio-frequency ablation
- In a randomized study of 126 women with menorrhagia randomized to RF ablation vs. hot-water-balloon ablation therapy, prevalence of amenorrhea was sig. greater in RF group at 3mos and 12mos (for the latter was 43% vs. 8%); pt satisfaction was also sig. greater at 12mos with RF treatment (BJOG 111:1095, 2004--AFP)
- Comparisons among treatments for menorrhagia
- In a meta-analysis of 30 randomized trials of treatment for menorrhagia, endometrial ablation was associated with sig. higher dissatisfaction rates than with hysterectomy (11-13% vs. 5%) but with no sig. difference from levonorgestrel-releasing IUDs (BMJ 341:c3929, 2010; e-pub ahead of printing at: http://dx.doi.org/10.1136/bmj.c3929).
(Sources include AFP 53:165, 1996)