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Management Strategies for Primary Menorrhagia

  • Roger P. Smith
Chapter

Abstract

Unlike primary dysmenorrhea, the managements of primary and secondary menorrhagia are often intertwined and complicated by the prevalence of difficult-to-identify secondary causes. When true primary menorrhagia is encountered, the same prostaglandin reduction strategies that work so well in primary dysmenorrhea work well for heavy menstrual bleeding. They also work well for many forms of secondary menorrhagia, raising the possibility that underlying pathologies may be missed if a careful assessment is not carried out before treatment, with equally careful monitoring after initiation. Treatment without such evaluation and care may miss symptoms of an easily corrected condition or neoplastic disease.

Keywords

Pharmacology Non-steroidal anti-inflammatory drug (NSAID) Hormonal treatment Antifibrinolytics Surgical management Decision tree Intrauterine therapy Contraception 

References

  1. 1.
    Peuranpää P, Heliövaara-Peippo S, Fraser I, Paavonen J, Hurskainen R. Effects of anemia and iron deficiency on quality of life in women with heavy menstrual bleeding. Acta Obstet Gynecol Scand. 2014;93(7):654–60.PubMedCrossRefGoogle Scholar
  2. 2.
    Royal New Zealand College of Obstetricians and Gynaecologists, Royal New Zealand College of General Practitioners. An evidence-based guideline for the management of heavy menstrual bleeding. Working Party for Guidelines for the Management of Heavy Menstrual Bleeding. N Z Med J. 1999;112(1088):174–7.Google Scholar
  3. 3.
    Ray S, Ray A. Non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders. Cochrane Database Syst Rev. 2014;(11):CD010338.Google Scholar
  4. 4.
    Fraser IS, Porte RJ, Kouides PA, Lukes AS. A benefit-risk review of systemic haemostatic agents: part 2: in excessive or heavy menstrual bleeding. Drug Saf. 2008;31(4):275–82.PubMedCrossRefGoogle Scholar
  5. 5.
    Zandstra D, Busser JA, Aarts JW, Nieboer TE. Interventions to support shared decision-making for women with heavy menstrual bleeding: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2017;211:156–63.PubMedCrossRefGoogle Scholar
  6. 6.
    Heikinheimo O, Fraser I. The current status of hormonal therapies for heavy menstrual bleeding. Best Pract Res Clin Obstet Gynaecol. 2017;40:111–20.PubMedCrossRefGoogle Scholar
  7. 7.
    Farquhar C, Brown J. Oral contraceptive pill for heavy menstrual bleeding. Cochrane Database Syst Rev. 2009;(4):CD000154.Google Scholar
  8. 8.
    Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011;117(4):777–87.PubMedCrossRefGoogle Scholar
  9. 9.
    Fraser IS, Parke S, Mellinger U, Machlitt A, Serrani M, Jensen J. Effective treatment of heavy and/or prolonged menstrual bleeding without organic cause: pooled analysis of two multinational, randomised, double-blind, placebo-controlled trials of oestradiol valerate and dienogest. Eur J Contracept Reprod Health Care. 2011;16(4):258–69.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Fraser IS, Jensen J, Schaefers M, Mellinger U, Parke S, Serrani M. Normalization of blood loss in women with heavy menstrual bleeding treated with an oral contraceptive containing estradiol valerate/dienogest. Contraception. 2012;86(2):96–101.PubMedCrossRefGoogle Scholar
  11. 11.
    Kiseli M, Kayikcioglu F, Evliyaoglu O, Haberal A. Comparison of therapeutic efficacies of norethisterone, tranexamic acid and levonorgestrel-releasing intrauterine system for the treatment of heavy menstrual bleeding: a randomized controlled study. Gynecol Obstet Investig. 2016;81(5):447–53.CrossRefGoogle Scholar
  12. 12.
    Heliövaara-Peippo S, Hurskainen R, Teperi J, et al. Quality of life and costs of levonorgestrel-releasing intrauterine system or hysterectomy in the treatment of menorrhagia: a 10-year randomized controlled trial. Am J Obstet Gynecol. 2013;209(6):535.e1–14.CrossRefGoogle Scholar
  13. 13.
    Xu L, Lee BS, Asif S, Kraemer P, Inki P. Satisfaction and health-related quality of life in women with heavy menstrual bleeding; results from a non-interventional trial of the levonorgestrel-releasing intrauterine system or conventional medical therapy. Int J Womens Health. 2014;6:547–54.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Sanghera S, Roberts TE, Barton P, et al. Levonorgestrel-releasing intrauterine system vs. usual medical treatment for menorrhagia: an economic evaluation alongside a randomised controlled trial. PLoS One. 2014;9(3):e91891.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Matteson KA, Rahn DD, Wheeler TL 2nd, et al. Society of Gynecologic Surgeons Systematic Review Group. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol. 2013;121(3):632–43.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Uhm S, Perriera L. Hormonal contraception as treatment for heavy menstrual bleeding: a systematic review. Clin Obstet Gynecol. 2014;57(4):694–717.PubMedCrossRefGoogle Scholar
  17. 17.
    Bitzer J, Heikinheimo O, Nelson AL, Calaf-Alsina J, Fraser IS. Medical management of heavy menstrual bleeding: a comprehensive review of the literature. Obstet Gynecol Surv. 2015;70(2):115–30.PubMedCrossRefGoogle Scholar
  18. 18.
    Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(3):625–32.PubMedCrossRefGoogle Scholar
  19. 19.
    Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, DeSanctis Y, Jensen J. Levonorgestrel-releasing intrauterine system for heavy menstrual bleeding improves hemoglobin and ferritin levels. Contraception. 2012;86(5):452–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Kaunitz AM, Inki P. The levonorgestrel-releasing intrauterine system in heavy menstrual bleeding: a benefit-risk review. Drugs. 2012;72(2):193–215.PubMedCrossRefGoogle Scholar
  21. 21.
    Hurskainen R, Grenman S, Komi I, et al. Diagnosis and treatment of menorrhagia. Acta Obstet Gynecol Scand. 2007;86(6):749–57.PubMedCrossRefGoogle Scholar
  22. 22.
    Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008;(1):CD001016.Google Scholar
  23. 23.
    Shaaban MM, Zakherah MS, El-Nashar SA, Sayed GH. Levonorgestrel-releasing intrauterine system compared to low dose combined oral contraceptive pills for idiopathic menorrhagia: a randomized clinical trial. Contraception. 2011;83(1):48–54.PubMedCrossRefGoogle Scholar
  24. 24.
    Lee BS, Ling X, Asif S, Kraemer P, Hanisch JU, Inki P. Levonorgestrel-releasing intrauterine system versus conventional medical therapy for heavy menstrual bleeding in the Asia-Pacific region. Int J Gynaecol Obstet. 2013;121(1):24–30.PubMedCrossRefGoogle Scholar
  25. 25.
    Qiu J, Cheng J, Wang Q, Hua J. Levonorgestrel-releasing intrauterine system versus medical therapy for menorrhagia: a systematic review and meta-analysis. Med Sci Monit. 2014;20:1700–13.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015;(4):CD002126.Google Scholar
  27. 27.
    Sanghera S, Frew E, Gupta JK, Kai J, Roberts TE. Exploring the use of cost-benefit analysis to compare pharmaceutical treatments for menorrhagia. PharmacoEconomics. 2015;33(9):957–65.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Maguire K, Joslin-Roher S, Westhoff CL, Davis AR. IUDs at 1 year: predictors of early discontinuation. Contraception. 2015;92(6):575–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Dahiya P, Dalal M, Yadav A, Dahiya K, Jain S, Silan V. Efficacy of combined hormonal vaginal ring in comparison to combined hormonal pills in heavy menstrual bleeding. Eur J Obstet Gynecol Reprod Biol. 2016;203:147–51.PubMedCrossRefGoogle Scholar
  30. 30.
    Abu Hashim H, Alsherbini W, Bazeed M. Contraceptive vaginal ring treatment of heavy menstrual bleeding: a randomized controlled trial with norethisterone. Contraception. 2012;85(3):246–52.PubMedCrossRefGoogle Scholar
  31. 31.
    Agarwal N, Gupta M, Kriplani A, Bhatla N, Singh N. Comparison of combined hormonal vaginal ring with ultralow-dose combined oral contraceptive pills in the management of heavy menstrual bleeding: a pilot study. J Obstet Gynaecol. 2016;36(1):71–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Janssen CA, Scholten PC, Heintz APA. Simple visual assessment technique to discriminate between menorrhagia and normal menstrual blood loss. Obstet Gynecol. 1995;85(6):977–82.PubMedCrossRefGoogle Scholar
  33. 33.
    Zakherah MS, Sayed GH, El-Nashar SA, Shaaban MM. Pictorial blood loss assessment chart in the evaluation of heavy menstrual bleeding: diagnostic accuracy compared with alkaline hematin. Gynecol Obstet Investig. 2011;71(4):281–4.CrossRefGoogle Scholar
  34. 34.
    Yiu KW, Chan SS, Chung TK. Mothers’ attitude to the use of a combined oral contraceptive pill by their daughters for menstrual disorders or contraception. Hong Kong Med J. 2017;23(2):150–7.PubMedGoogle Scholar
  35. 35.
    Agarwal N, Kriplani A. Medical management of dysfunctional uterine bleeding. Int J Gynecol Obstet. 2001;75(2):199–201.CrossRefGoogle Scholar
  36. 36.
    Maybin JA, Critchley HO. Medical management of heavy menstrual bleeding. Womens Health (Lond). 2016;12(1):27–34.CrossRefGoogle Scholar
  37. 37.
    Hall P, Maclachlan N, Horn N, Nudd MWE, Taylor CG, Garrioch DB. Control of menorrhagia by the cyclo-oxygenase inhibitors naproxen sodium and mefenamic acid. Br J Obstet Gynaecol. 1987;94:554–8.PubMedCrossRefGoogle Scholar
  38. 38.
    van Eijkeren MA, Christiaens GC, Geuze HJ, Haspels AA, Sixma JJ. Effects of mefenamic acid on menstrual haemostasis in essential menorrhagia. Am J Obstet Gynecol. 1992;166(5):1419–28.PubMedCrossRefGoogle Scholar
  39. 39.
    Khajehei M, Abdali K, Tabatabaee H. The effect of mefenamic acid and naproxen on heavy menstrual bleeding: a placebo-controlled study. S Afr J OG. 2013;19(2):31–4.CrossRefGoogle Scholar
  40. 40.
    Fraser IS, McCarron G, Markham R, Robinson M, Smyth E. Long-term treatment of menorrhagia with mefenamic acid. Obstet Gynecol. 1983;61(1):3–6.Google Scholar
  41. 41.
    Reid PC, Virtanen-Kari S. Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. Br J Obstet Gynecol. 2005;112(8):8–14.CrossRefGoogle Scholar
  42. 42.
    Coulter A, Long A, Kelland J, et al. Managing menorrhagia. Qual Health Care. 1995;4(3):218–26.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;(1):CD000400.Google Scholar
  44. 44.
    Bonner J, Sheppard BL. Treatment of menorrhagia during menstruation: randomized controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. BMJ. 1996;313:579–82.CrossRefGoogle Scholar
  45. 45.
    Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249.Google Scholar
  46. 46.
    Philipp CS. Antifibrinolytics in women with menorrhagia. Thromb Res. 2011;127(Suppl 3):S113–5.PubMedCrossRefGoogle Scholar
  47. 47.
    Leminen H, Hurskainen R. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health. 2012;4:413–21.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Preston JT, Cameron IT, Adams EJ, Smith SK. Comparative study of tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. Br J Obstet Gynaecol. 1995;102:401–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999;57(6):1005–32.PubMedCrossRefGoogle Scholar
  50. 50.
    Srivaths LV, Dietrich JE, Yee DL, Sangi-Haghpeykar H, Mahoney D Jr. Oral tranexamic acid versus combined oral contraceptives for adolescent heavy menstrual bleeding: a pilot study. J Pediatr Adolesc Gynecol. 2015;28(4):254–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Iacobellis G, Iacobellis G. Combined treatment with tranexamic acid and oral contraceptive pill causes coronary ulcerated plaque and acute myocardial infarction. Cardiovasc Drugs Ther. 2004;18(3):239–40.PubMedCrossRefGoogle Scholar
  52. 52.
    Wijetilleka S, Yeo DCM, Sharma B. Central retinal artery occlusion in a 30-year-old woman taking tranexamic acid. BMJ Case Rep. 2017 July 13;2017. pii: bcr-2016-218246.Google Scholar
  53. 53.
    Edlund M. Nonhormonal treatments for heavy menstrual bleeding. J Womens Health (Larchmt). 2011;20(11):1645–53.CrossRefGoogle Scholar
  54. 54.
    Lukes AS, Moore KA, Muse KN, et al. Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116(4):865–75.PubMedCrossRefGoogle Scholar
  55. 55.
    Monell SH. A system of instruction in X-ray methods and medical uses of light, hot-air, vibration and high-frequency currents: a pictorial system of teaching by clinical instruction plates with explanatory text: a series of photographic clinics in standard uses of scientific therapeutic apparatus for surgical and medical practitioners: prepared especially for the post-graduate home study of surgeons, general physicians, dentists, dermatologists and specialists in the treatment of chronic diseases, and sanitarium practice. New York: E.R. Pelton; 1902, plate 372.Google Scholar
  56. 56.
    Kashefi F, Khajehei M, Alavinia M, Golmakani E, Asili J. Effect of ginger (Zingiber officinale) on heavy menstrual bleeding: a placebo-controlled, randomized clinical trial. Phytother Res. 2015;29(1):114–9.PubMedCrossRefGoogle Scholar
  57. 57.
    Javan R, Yousefi M, Nazari SM, et al. Herbal medicines in idiopathic heavy menstrual bleeding: a systematic review. Phytother Res. 2016;30(10):1584–91.PubMedCrossRefGoogle Scholar
  58. 58.
    Tansaz M, Memarzadehzavareh H, Qaraaty M, Eftekhar T, Tabarrai M, Kamalinejad M. Menorrhagia management in Iranian traditional medicine. J Evid Based Complement Altern Med. 2016;21(1):71–6.CrossRefGoogle Scholar
  59. 59.
    Farquhar C, Steiner C. Hysterectomy rates in the United States 1990–1997. Obstet Gynecol. 2002;99:229–34.PubMedGoogle Scholar
  60. 60.
    Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2016;(1):CD003855.Google Scholar
  61. 61.
    Kuppermann M, Varner RE, Summitt RL Jr, et al. Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning: the medicine or surgery (Ms) randomized trial. JAMA. 2004;291:1447–55.PubMedCrossRefGoogle Scholar
  62. 62.
    Hassanin IM, Shahin AY, Abdel-Hafeez AT, Salem HT, El-Nashar SA. Bilateral uterine artery ligation via minilaparotomy for heavy menstrual bleeding. Int J Gynaecol Obstet. 2008;103(3):222–6.PubMedCrossRefGoogle Scholar
  63. 63.
    Showstack J, Lin F, Learman LA, et al. Randomized trial of medical treatment versus hysterectomy for abnormal uterine bleeding: resource use in the medicine or surgery (Ms) trial. Am J Obstet Gynecol. 2006;194:332–8.PubMedCrossRefGoogle Scholar
  64. 64.
    Learman LA, Summitt RL Jr, Varner RE, et al. Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: clinical outcomes in the medicine or surgery trial. Obstet Gynecol. 2004;103:824–33.PubMedCrossRefGoogle Scholar
  65. 65.
    Brown PM, Farquhar CM, Lethaby A, Sadler LC, Johnson NP. Cost-effectiveness analysis of levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. BJOG. 2006;113(7):797–803.PubMedCrossRefGoogle Scholar
  66. 66.
    Aberdeen Endometrial Ablation Trials Group. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. Aberdeen Endometrial Ablation Trials Group. Br J Obstet Gynaecol. 1999;106(4):360–6.CrossRefGoogle Scholar
  67. 67.
    Fergusson RJ, Lethaby A, Shepperd S, Farquhar C. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;(11):CD000329.Google Scholar
  68. 68.
    Daniels JP, Middleton LJ, Champaneria R, et al. International Heavy Menstrual Bleeding IPD Meta-analysis Collaborative Group. Second generation endometrial ablation techniques for heavy menstrual bleeding: network meta-analysis. BMJ. 2012;344:e2564.PubMedPubMedCentralCrossRefGoogle Scholar
  69. 69.
    Vihko KK, Raitala R, Taina E. Endometrial thermoablation for treatment of menorrhagia: comparison of two methods in outpatient setting. Acta Obstet Gynecol Scand. 2003;82(3):269–74.PubMedCrossRefGoogle Scholar
  70. 70.
    Al-Shaikh G, Almalki G, Bukhari M, Fayed A, Al-Mandeel H. Effectiveness and outcomes of thermablate endometrial ablation system in women with heavy menstrual bleeding. J Obstet Gynaecol. 2017;37(6):770–4.PubMedCrossRefGoogle Scholar

Additional Resources

  1. American College of Obstetricians and Gynecologists. Endometrial ablation. ACOG Practice Bulletin No. 81. Obstet Gynecol. 2007;109:1233–48.CrossRefGoogle Scholar
  2. American College of Obstetricians and Gynecologists. Alternatives to hysterectomy in the management of leiomyomas. ACOG Practice Bulletin No. 96. Obstet Gynecol. 2008;112:201–7.CrossRefGoogle Scholar
  3. American College of Obstetricians and Gynecologists. Noncontraceptive uses of hormonal contraceptives. Practice Bulletin No. 110. Obstet Gynecol. 2010;115:206–18.CrossRefGoogle Scholar
  4. American College of Obstetricians and Gynecologists. Management of abnormal uterine bleeding associated with ovulatory dysfunction. Practice Bulletin No. 136. Obstet Gynecol. 2013;122:176–85.CrossRefGoogle Scholar
  5. American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. Obstet Gynecol. 2013;121:891–6.CrossRefGoogle Scholar
  6. American College of Obstetricians and Gynecologists. Von Willebrand disease in women. Committee Opinion No. 580. Obstet Gynecol. 2013;122:1368–73.CrossRefGoogle Scholar
  7. American College of Obstetricians and Gynecologists. Options for prevention and management of heavy menstrual bleeding in adolescent patients undergoing cancer treatment. Committee Opinion No. 606. Obstet Gynecol. 2014;124:397–402.CrossRefGoogle Scholar
  8. Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol. 2016;214(1):31–44.PubMedCrossRefGoogle Scholar
  9. Davies J, Kadir RA. Heavy menstrual bleeding: an update on management. Thromb Res. 2017;151(Suppl 1):S70–7.PubMedCrossRefGoogle Scholar
  10. Fraser IS, Zeun S, Parke S, Wilke B, Junge W, Serrani M. Improving the objective quality of large-scale clinical trials for women with heavy menstrual bleeding: experience from 2 multi-center, randomized trials. Reprod Sci. 2013;20(7):745–54.PubMedCrossRefGoogle Scholar
  11. Kumar V, Chodankar R, Gupta JK. Endometrial ablation for heavy menstrual bleeding. Womens Health (Lond). 2016;12(1):45–52.CrossRefGoogle Scholar
  12. Leebeek FW, Eikenboom JC. Von Willebrand’s disease. N Engl J Med. 2016;375(21):2067–80.PubMedCrossRefGoogle Scholar
  13. Mishell DR Jr, Fisher HW, Haynes PJ, Jones GS, Smith RP. Menorrhagia: a symposium. J Reprod Med. 1984;29(10 Suppl):763–82.PubMedGoogle Scholar
  14. Oehler MK, Rees MC. Menorrhagia: an update. Acta Obstet Gynecol Scand. 2003;82(5):405–22.PubMedCrossRefGoogle Scholar
  15. Rodeghiero F. Management of menorrhagia in women with inherited bleeding disorders: general principles and use of desmopressin. Haemophilia. 2008;14(Suppl 1):21–30.PubMedGoogle Scholar
  16. Smith RP. Netter’s obstetrics & gynecology. 3rd ed. Philadelphia: Elsevier; 2017. p. 274–6.Google Scholar
  17. Wellington K, Wagstaff AJ. Tranexamic acid: a review of its use in the management of menorrhagia. Drugs. 2003;63:1417–33.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Roger P. Smith
    • 1
  1. 1.Florida Atlantic UniversityBoca RatonUSA

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