Management of heavy menstrual bleeding

Not everyone needs referral to secondary care (1) and treatment of menorrhagia may be surgical or medical. Surgery is usually indicated in cases of proven pathology, for example, uterine fibroids. Non-hormonal and hormonal agents may be used when the cause is uncertain or the woman is keen to retain her fertility.

NICE suggest that, in cases of menorrhagia/heavy menstrual bleeding, pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity.

When a first pharmaceutical treatment has proved ineffective then a second pharmaceutical treatment should be considered rather than immediate referral to surgery.

First-line treatment (1)

This is the LNG-IUS - Mirena®. This should be left in situ for at least 12 months. Women with menorrhagia report improvement in bleeding and are likely to continue with this treatment. (2)

Comparing the IUS to oral treatments, endometrial ablation and hysterectomy, an IUS is more effective than oral treatment, results in more reduction in bleeding and more improvement in quality of life and is more acceptable long-term. (3)

Second-line treatment (1)

This includes tranexamic acid, non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid, or the combined oral contraceptive (COC) (4,5,6)

Third-line treatment (1)

Progestogens such as norethisterone 5 mg tds from day 5 to 26, or injected long-acting progestogens such as medroxyprogesterone acetate (Depo-Provera®) every 12 weeks. These are less effective than other medical options (7) and there is no consensus about which is most effective. (8)

Gonadotrophin-releasing hormone (GnRH) analogues may be offered for a few months before hysterectomy or myomectomy, where the uterus is enlarged or distorted by fibroids, or before endometrial ablative surgery. (9)

Ulipristal acetate is only indicated for some premenopausal women with fibroids that have a diameter of at least 3 cm. (1) They should be advised that ulipristal acetate can be associated with serious liver injury leading to liver failure and that LFTs should be measured before starting treatment, monthly for the first two courses and once before each new treatment course when clinically indicated. (10)

Surgery

Surgery, and in particular hysterectomy, improves heavy menstrual bleeding more effectively than medical options (11). Endometrial ablation is the recommended first-line treatment if the uterus is <10 weeks of gestation on palpation. (1) If the uterus is >10 weeks in size and the woman wishes to retain her uterus, treatment options are uterine artery embolisation or hysteroscopic myomectomy (12)

If the patient does not wish to retain the uterus, then treatment may be with hysterectomy - first consider vaginal, then abdominal with conservation of ovaries, if appropriate. Healthy ovaries should not be removed. (1)

References:

1. Heavy menstrual bleeding: assessment and management. NG88. NICE Guideline (March 2018 - updated May 2021)
2. Bofill Rodriguez M et al. Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev. 2022 May 31;5(5)
3. Bofill Rodriguez M, Lethaby A, Jordan V. Progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2020 Jun 12;6(6)
4. Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Sep 19;9
5. Bryant-Smith AC, Lethaby A, Farquhar C, et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018 Apr 15;4(4)
6. Lethaby A, Wise MR, Weterings MA, et al. Combined hormonal contraceptives for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Feb 11;2
7. Bofill Rodriguez M, Lethaby A, Low C, et al. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Aug 14;8
8. Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. 2012 Sep 12;9
9. Tan YH, Lethaby A. Pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013 Nov 15;11
10. Ulipristal acetate 5 mg (Esmya). Further restrictions due to risk of serious liver injury; GOV.UK (Feb 2021)
11. Marjoribanks J et al. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2016 Jan 29;1
12. Fatima K, Ansari HW, Ejaz A, et al. Uterine artery embolization versus myomectomy: a systematic review and meta-analysis. SAGE Open Med. 2024 May 14;12