Menorrhagia Management

Aka: Menorrhagia Management, Ovulatory Bleeding Management

1. See Also
   1. Ovulatory Bleeding (Menorrhagia)
   2. Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding)
   3. Menstrual Cycle
   4. Abnormal Uterine Bleeding Causes
   5. Anovulatory Bleeding (Metrorrhagia)
   6. Uterine Bleeding in Pregnancy
   7. First Trimester Bleeding
   8. Late Pregnancy Bleeding
   9. Endometrial Cancer Screening
   10. Oral Contraceptive-Related Uterine Bleeding Management
   11. Postmenopausal Bleeding
   12. Amenorrhea
   13. Lower GI Bleed
   14. Hematuria
2. Management: General
   1. Suppress Ovulation and Endometrial Thickening
      1. Progesterone
         1. Provera 10 mg PO daily on days 5-26 of cycle (21 days per month)
         2. Avoid Luteal Phase only (10 day) - low efficacy
      2. Combination Oral Contraceptive 1 tab orally daily
         1. Conventional 28 day cycling
         2. Loestrin 1.5/30
            1. High Androgenic Activity
            2. High Progestational Activity
            3. Low Estrogenic Activity
      3. Progestin containing IUD (Mirena): Preferred option
         1. May reduce blood loss by 90%
         2. Levonorgestrel IUD is a good Hysterectomy alternative
            1. Hurskainen (2004) JAMA 291:1456-63
      4. Depo-Provera 150mg IM every 11-13 weeks
   2. Advanced options used in some cases by Gynecology
      1. Danazol (Danocrine) - Androgenic Steroid
         1. Dose: 200-400 mg PO qd for 6-9 months
         2. Androgenic side effects!
      2. GnRH agonist
         1. Daily or monthly injection for 4-6 months
         2. Add back Estrogen
   3. Therapies that modulate Bleeding Diathesis
      1. Tranexamic acid (Lysteda)
         1. Antifibrinolytic that prevents plasminogen activation
         2. Dose: Take two 650 mg tabs orally three times daily for the first 5 days of the cycle
         3. More effective than NSAIDs
         4. Very expensive
         5. Initial concern regarding risk of thrombosis, however follow-up studies demonstrated no increased risk
   4. Correct relative prostaglandin overproduction
      1. Use NSAID for 3 days starting with Menses
      2. NSAID Options
         1. Mefenamic acid (Ponstel) 500 mg PO tid
         2. Naproxen (Anaprox, Naprosyn) 500 mg PO bid
         3. Ibuprofen 200-400 mg 1 tab PO q4-6h
   5. Other adjunctive treatment
      1. Erythropoietin recombinant (not routinely recommended)
         1. Helps to rapidly correct Anemia
      2. Endometritis Management
         1. Doxycycline 100 mg PO bid for 10 days
3. Management: Severe or acute Menorrhagia (Hemoglobin <10)
   1. Hospitalization Indication
      1. Hemoglobin <7 or symptomatic Anemia
      2. Comorbid conditions
   2. Estrogen-only Option (with Antiemetic)
      1. Initial
         1. Premarin 2.5 mg PO q6h or 25 mg IV q4h
         2. Antiemetic needed concurrently
      2. After 12-24 hours
         1. Premarin 2.5mg PO q6h x5 days
         2. Provera 10 mg PO qd x5 days
      3. After 5-7 days
         1. Premarin 2.5 mg PO daily
         2. Provera 5-10 mg PO daily
   3. Combination OCP option
      1. Formulation: Progestin-dominant OCP (e.g. Ovral)
         1. Ethinyl Estradiol 0.05 mg
         2. Norgestrel 0.5 mg
      2. Protocol (Prescribe 3 packs)
         1. Concurrently prescribe Antiemetic
         2. Ovral 1 PO qid until bleeding stops (~48h) THEN
         3. Ovral 1 PO tid for 7 days THEN
         4. Ovral 1 PO bid for 10 days THEN
         5. Ovral 1 PO qd for 21 days
   4. Estrogen IV Method
      1. First
         1. Premarin 25 mg IV q4h over 30 minutes up to 6 doses
      2. Next
         1. Premarin 2.5 mg PO tid for 10 days
         2. Provera 10 mg PO qd for 10 days
      3. Next
         1. Allow withdrawal bleeding for 5 days
      4. Next for 3-6 cycles
         1. Option 1: Oral Contraceptive
         2. Option 2: Provera 10 mg PO cycle days 5 to 26
4. Management: Refractory Bleeding
   1. Uterine Foley (For bleeding not controlled by above)
      1. Foley balloon filled with 30 cc of water
   2. Direct Uterine irrigation (For refractory bleeding)
      1. Uterine irrigation with Aminocaproic Acid (AMICAR)
         1. Potent Fibrinolysis Inhibitor
5. Management: Surgical
   1. Dilatation and Curettage (D&C)
      1. Immediately follow with Oral Contraceptive use
   2. Global Endometrial Ablation (preferred option)
      1. Older, hysteroscope procedures (first generation)
         1. Example: Rollerball, Transcervical resection
      2. Newer, non-hysteroscope procedures (preferred)
         1. Higher efficacy, lower complication rates
         2. Examples: Laser, microwave, thermal balloon, cryo
   3. Hysterectomy (high rate of adverse effects)
   4. References
      1. Sowter (2003) Lancet 361:1456-8
6. References
   1. Nelson (1997), Fam Prac Recert 19(8):14
   2. Apgar (2007) Am Fam Physician 75(12):1813-20
   3. Buchanan (2009) Am Fam Physician 80(10): 1075-88
   4. Dilley (2001) Obstet Gynecol 97:630-6
   5. Sweet (2012) Am Fam Physician 85(1): 35-43