Menorrhagia Management

Aka: Menorrhagia Management, Ovulatory Bleeding Management, Heavy Menstrual Bleeding Management, Emergent Management of Acute Heavy Uterine Bleeding

1. See Also
   1. Ovulatory Bleeding (Menorrhagia)
   2. Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding)
   3. Metrorrhagia Management (Anovulatory Bleeding Management)
   4. Menstrual Cycle
   5. Abnormal Uterine Bleeding Causes
   6. Anovulatory Bleeding (Metrorrhagia)
   7. Uterine Bleeding in Pregnancy
   8. First Trimester Bleeding
   9. Late Pregnancy Bleeding
   10. Endometrial Cancer Screening
   11. Oral Contraceptive-Related Uterine Bleeding Management
   12. Postmenopausal Bleeding
   13. Amenorrhea
   14. Lower GI Bleed
   15. 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) OR
         2. Norethindrone 2.5 to 5 mg orally once daily on days 5-26 of cycle (21 days per month)
         3. Avoid Luteal Phase only (10 day) - low efficacy
      2. Combination Oral Contraceptive 1 tab orally daily
         1. Reduce blood loss by 50% in women with heavy Menstrual Bleeding
         2. Conventional 28 day cycling
         3. Loestrin 1.5/30
            1. High Androgenic Activity
            2. High Progestational Activity
            3. Low Estrogenic Activity
         4. Natazia (Estradiol + Dienogest)
            1. First Oral Contraceptive FDA approved specifically for Menorrhagia (2012)
            2. However, expensive and does not offer any additional benefit over Loestrin or other generic OCP
         5. References
            1. (2012) Presc Lett 19(5): 27
            2. Jensen (2011) Obstet Gynecol 117(4):777-87 [PubMed]
      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 [PubMed]
      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. Oral: Take two 650 mg (or 20-25 mg/kg) tabs orally three times daily for the first 5 days of the cycle
         3. IV: 10 mg/kg IV every 8 hours
         4. More effective than NSAIDs
         5. Initial concern regarding risk of thrombosis, however follow-up studies demonstrated no increased risk
   4. Correct relative Prostaglandin overproduction
      1. NSAIDs reduce Prostaglandin levels via cyclooxygenase inhibition
         1. Reduce menstrual flow by 20-46%
      2. Use NSAID for 3-5 days starting with Menses
      3. NSAID Options
         1. Mefenamic acid (Ponstel) 500 mg orally three times daily
         2. Naproxen (Anaprox, Naprosyn) 500 mg orally twice daily
         3. Ibuprofen 600 mg orally every 6 hours
   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. Monitor for hemodynamic instability
      1. Consult gynecology early for possible surgical or procedural intervention
      2. Type and cross for Blood Products
   2. See Tranexamic Acid (Lysteda) above
   3. Consult with gynecology if Estrogen protocol started
   4. Prescribe Antiemetic (e.g. Ondansetron) to any of these protocols (due to high dose Estrogen)
   5. Estrogen Contraindications (even for brief courses)
      1. Venous thromboebolism
      2. Estrogen responsive cancer
   6. Hospitalization Indication
      1. Hemoglobin <7 or symptomatic Anemia
      2. Comorbid conditions
   7. Estrogen Oral Method
      1. Initial
         1. Premarin 2.5 mg PO q6h or 25 mg IV every 4-6 hours
         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 (start when bleeding subsides)
      3. After 5-7 days
         1. Premarin 2.5 mg PO daily
         2. Provera 5-10 mg PO daily
   8. Combination OCP option with
      1. Contraindications
         1. See Oral Contraceptives
         2. Estrogen-dependent tumor
         3. Venous Thromboembolism or Cerebrovascular Accident
         4. Active liver disease
         5. Pregnancy
         6. Age over 35 years old and Tobacco use >15 Cigarettes daily
         7. Hypertriglyceridemia
      2. Preparations
         1. Use Progestin-dominant OCP with at least 0.030 mg Estrogen
         2. Norgestrel 0.5 mg and Ethinyl Estradiol 0.05 mg
            1. Ovral
         3. Norethindrone 1 mg and Ethinyl Estradiol 0.035 mg
            1. Ortho Novum 1/35
            2. Norinyl 1/35
            3. Necon 1/35
            4. Dasetta 1/35
            5. Alyacen 1/35
      3. Protocol (Prescribe 3 packs)
         1. Concurrently prescribe Antiemetic
         2. Take 1 tablet 4 times daily for 2-4 days (until bleeding stops), then
         3. Take 1 tablet 3 times daily for 3-7 days, then
         4. Take 1 tablet 2 times daily for 2 days, then
         5. Take 1 tablet daily for 3 weeks, then
         6. Skip one week of pills to allow for withdrawal bleeding, and then
         7. Cycle on Oral Contraceptives for 3 months or more
   9. Estrogen IV Method
      1. First
         1. Premarin 25 mg IV every 4-6 hours (up to every 2 hours) over 30 minutes up to 6 doses
      2. Next
         1. Premarin 2.5 mg orally three times daily for 10 days
         2. Provera 10 mg orally daily for 10 days (start when bleeding subsides)
      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 Uterine Bleeding
   1. Uterine Foley (For bleeding not controlled by above)
      1. Foley Catheter inserted into Uterus
      2. Foley balloon filled with 30 cc of water or saline or until bleeding stops
   2. Direct Uterine irrigation (For refractory bleeding)
      1. Uterine irrigation with Aminocaproic Acid (AMICAR)
         1. Potent Fibrinolysis Inhibitor
5. Management: Surgical Management of Uterine Bleeding
   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 [PubMed]
6. Management: Vaginal Bleeding (e.g. vaginal Laceration)
   1. Rectal tube inserted into vagina
      1. Inflate to tamponade bleeding
   2. Vaginal packing with gauze
      1. Risk of infection (Toxic Shock Syndrome)
      2. Use for brief period to temporize until definitive therapy
7. Resources
   1. NIH Heavy Menstrual Bleeding Assessment and Management
8. References
   1. Mace (2013) Crit Dec Emerg Med 27(2): 13-21
   2. Nelson (1997), Fam Prac Recert 19(8):14
   3. (2013) Obstet Gynecol 122(1):176-85 [PubMed]
   4. Apgar (2007) Am Fam Physician 75(12):1813-20 [PubMed]
   5. Buchanan (2009) Am Fam Physician 80(10): 1075-88 [PubMed]
   6. Dilley (2001) Obstet Gynecol 97:630-6 [PubMed]
   7. Sweet (2012) Am Fam Physician 85(1): 35-43 [PubMed]
   8. Wouk (2019) Am Fam Physician 99(7): 435-43 [PubMed]
   9. Sriprasert (2017) Contracept Reprod Med 2:20 +PMID:29201425 [PubMed]