Approach to treatment of heavy menstrual bleeding

The aims of management of heavy menstrual bleeding are to reduce impact on quality of life and to treat any underlying pathology. If no pathology has been found, choice of treatment for heavy menstrual bleeding depends on several factors such as patient preference, coexisting medical conditions, and desire for contraception or conception. See Approach to investigating and treating heavy menstrual bleeding for an approach to investigation and treatment. See also Indications for specialist referral, including advice on early referral.

Intermenstrual bleeding and postcoital bleeding require separate investigation and management; they should not be treated as for heavy menstrual bleeding.

In individuals not seeking to conceive, treat heavy menstrual bleeding with one of the following options:

the 52 mg levonorgestrel-releasing intrauterine contraceptive device (LNG-IUD)—the most effective drug therapy for heavy menstrual bleeding
nonhormonal options (tranexamic acid, nonsteroidal anti-inflammatory drug (NSAIDs) or combined hormonal contraception—considered equivalent second-line options
oral progestogens or depot medroxyprogesterone—can be used if other options are contraindicated, or according to patient preference.

In individuals trying to conceive, or with other contraindications to hormonal treatment, nonhormonal drug treatment with tranexamic acid or an NSAID is suitable first-line treatment for heavy menstrual bleeding.

Tranexamic acid is more effective than NSAIDs so is usually the preferred nonhormonal option. However, it is not useful for dysmenorrhoea; NSAIDs and all hormonal treatments have shown benefit for concurrent dysmenorrhoea.

Tranexamic acid and NSAIDs can be used together, and can also be combined with hormonal drug treatment, if required.

If heavy menstrual bleeding has not settled after at least 6 months of pharmacotherapy, refer for specialist assessment and consideration of surgical options.