Management options in menorrhagia

A medical approach should be considered first-line treatment in the management of menorrhagia. Luteal phase progestogens may regulate irregular bleeding secondary to anovulatory cycles. Oral progestogens are not useful for ovulatory dysfunctional uterine bleeding when given as a luteal supplement. They must be given for at least 21 days per month or via the intrauterine route to reduce menstrual blood loss (MBL). Intrauterine progestogen delivery holds great promise in the treatment of menorrhagia because it can induce a dramatic reduction in MBL. When bleeding is heavy and regular, prostaglandin synthetase inhibitors (PGSIs) taken during menstruation may decrease bleeding and relieve dysmenorrhoea. Tranexamic acid is an alternative to PGSIs for heavy and regular bleeding, but should be avoided in those with thrombosis risk factors. Hormonal treatment of heavy regular bleeding should include a trial of the oral contraceptive pill if there are no contraindications. Danazol, gestrinone and gonadotrophin-releasing hormone agonists are only suitable for short-term therapy of heavy regular-bleeding. Medical treatment can reduce excessive MBL by more than 50%. However, as only 40-50% of women referred to specialist care with a convincing history of menorrhagia actually lose more than 80 ml of blood, it often appears to fail. Apparent failure of medical therapy should prompt the clinician to reconsider the diagnosis rather than to immediately consider surgery. (author abstract)