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Menorrhagia (heavy menstrual bleeding) - Management
Which pharmaceutical treatment should I prescribe in a woman with menorrhagia?

Treatments for menorrhagia should be considered in the following order:

  • The levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena®) is the preferred first-choice, provided that long-term contraception with an intrauterine device is acceptable (anticipated minimum use of 12 months).
  • Tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), or the combined oral contraceptive pill (COC) should be considered second, if LNG-IUS is unsuitable.
    • Tranexamic acid and NSAIDs are suitable if contraception is not desired and are first-choice drugs while investigations or definitive treatment is being organized.
      • If dysmenorrhoea is present, NSAIDs may be preferred, as they provide relief of menstrual pain.
      • CKS recommends that if an NSAID is to be used, mefenamic acid, naproxen, or ibuprofen should be prescribed.
    • The COC offers more readily reversible contraception than the LNG-IUS. It also has the benefit of regulating cycles and reducing dysmenorrhoea.
  • Oral norethisterone or long-acting progestogens should be considered third choice if the other treatments are unsuitable.
    • Oral norethisterone should be taken during the follicular and luteal phases (days 5 to 26). It is not an effective form of contraception. However, a dose that is effective in decreasing menstrual blood loss is also likely to inhibit ovulation, and so its use is not appropriate in women wishing to conceive.
    • Depot medroxyprogesterone acetate (Depo-Provera®) is the recommended long-acting progestogen. It is taken as an intramuscular injection once every 12 weeks.
  • Danazol, gestrinone, and etamsylate are not recommended for the treatment of menorrhagia.
  • Gonadotropin-releasing hormone analogues (e.g. leuprorelin or buserelin) are not recommended for use in primary care, but are an option in secondary care. For more information, see Management in secondary care.

For more information on prescribing drugs to treat menorrhagia, see Prescribing information sections on Levonorgestrel-releasing intrauterine system, Tranexamic acid, Nonsteroidal anti-inflammatory drugs, Combined oral contraceptives, Oral norethisterone, and Long-acting progestogens.

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