The important conditions to rule out first include pregnancy, endometrial hyperplasia (abnormal thickening of the lining of the womb) and endometrial carcinoma.

If there are organic causes of menorrhagia, such as fibroids or adenomyosis, treatment options can be offered based on your wishes and fertility concerns.

If there is suspected chronic endometritis (risk factors include recent childbirth or intrauterine procedure), this can often be treated with a course of antibiotics.

If you are found to be anaemic, iron supplementation is usually recommended.

The general considerations guiding the choice of initial treatment are:

• Reason and severity of bleeding
• Associated symptoms (e.g. pelvic pain, infertility)
• Fertility – Contraceptive needs or plans for future pregnancy
• Contraindications to hormonal or other medications
• Medical comorbidities
• Restriction of activities due to heavy flow
• Patient preferences regarding medical versus surgical and shortterm versus long-term therapies

In the absence of any structural or histological abnormalities, or fibroids more than 3 cm causing distortion of uterine cavity, the recommendations for treatment are:

First line:

1. Levonorgestrel intrauterine system (LNG-IUD) - Mirena

• This is a hormone-releasing intrauterine device which can last for five years. Studies have shown this to be more effective than other medical treatments.
• This option reduces blood loss by up to 94 percent. Some women experience an increase in irregular or heavy bleeding during the first three months after placement of the LNG-IUD. After three months, the most common bleeding pattern in previously menorrhagic women is spotting, and after six months, the majority of patients have amenorrhoea (absence of menstruation) or oligomenorrhoea (infrequent menstruation).
• Other benefits include reduction in dysmenorrhoea (painful menses) in patients with endometriosis or adenomyosis, reduction in endometrial cancer risk, as well as birth control.

Second line:

1. Tranexamic acid

• This medication works by stabilising a protein that helps blood to clot. It can reduce flow by up to 50 percent and is taken three or four times a day, for a maximum of three to four days during the period.
• This medication is non-hormonal in nature and will not affect fertility.

2. Non-steroidal anti-inflammatory drugs (NSAIDs)

• Medications in this class of drug include ponstan (mefenamic acid), naproxen (synflex), ibuprofen.
• NSAIDs work by reducing your body’s production of prostaglandin from the womb, which is linked to heavy periods. NSAIDs are also painkillers. They do not affect your fertility and are taken during your period.
• The reduction in blood loss is by 33-55 percent.
• Side effects include nausea, vomiting and diarrhoea.

3. Combined oral contraceptive pill (COCP)

• These contain two hormones – oestrogen and progestogen.
• There is a reduction of menstrual blood loss by around 40 percent.
• Other benefits include birth control, regulation of cycle, improvement in pre-menstrual symptoms, reduction in painful menses and protection of the ovaries and endometrium (womb lining) against cancer.

Third line:

1. Norethisterone

• This is a type of man-made progestogen (one of the female sex hormones).
• This is taken, from day 5 to 26 of the menstrual cycle.
• It is not an effective form of birth control and may have side effects such as weight gain, breast tenderness and acne.
• It is usually used for short-term treatment of menorrhagia.

2. Progestogen injection

• A type of progestogen called medroxyprogesterone acetate is also available as an injection and is sometimes used to treat menorrhagia.
• This is useful for contraception and is usually given threemonthly. This treatment is usually limited to two years due to risk of bone loss with prolonged use.
• Side effects include weight gain, irregular bleeding, occasional delayed return to fertility after stopping the medication.

3. GnRH analogue

• This is hormone medication given to mimic menopause (it lowers the female hormones in the body).
• It is not a routine treatment but may be used to shrink fibroids before operation and control bleeding to allow anaemia to recover before surgery.

This may be considered also if you are close to menopause and other treatments are not working or contraindicated.

Surgical options

The choice of treatment will depend on both the uterine size and the patient’s desire to retain her uterus.

1. Endometrial ablation

• This option can be considered if the uterus size is not too large or distorted by fibroids. You will also need to use a reliable form of contraception after the treatment as pregnancy is contraindicated due to the high risk of problems.
• This involves removing the full thickness of the lining of the womb.

2. Uterine artery embolisation

• This involves injecting small plastic beads to block the arteries supplying the womb.
• This is usually offered to women who have heavy menses due to large fibroids, as blocking the blood supply will cause the fibroids to shrink with time.

3. Hysterectomy (removal of the womb)

• This option can be considered when other options have been exhausted and the patient chooses not to retain her fertility. * If menorrhagia is due to fibroids, surgical treatment may include myomectomy (surgery to remove fibroids), rather than hysterectomy.