How can I reduce or stop heavy bleeding?

1 in 4 Women Experience Heavy Periods 1

Many women believe that hormone therapy or surgical removal of the uterus (i.e. hysterectomy) are their only options if they experience heavy menstrual bleeding. There are other treatments available that do not involve hormones or major surgery.

Together with your doctor, you can decide which treatment is most suitable for you. Your doctor will discuss the amount and frequency of your blood loss and other symptoms you may be experiencing, as well as the impact of your periods on your everyday life. Your most suitable treatment will most likely depend on several factors, including:

  • Severity of bleeding
  • Whether you want children in the future or consider your family complete
  • Whether you prefer a long-term or one-off treatment
  • Whether you want to take hormones or not
Choosing the right treatment for you

Choosing the right treatment for you

Remember, the right choice for you will depend on a number of factors and should be determined in consultation with your doctor. There are several treatment options available for heavy menstrual bleeding. Generally speaking, they fall into two categories:

Non-hormonal options can include certain medication, minimally invasive surgery or major surgery such as a hysterectomy.

Hormonal options typically include the oral contraceptive pill or a hormonal intrauterine device (IUD).

 

 

Non-hormonal options

Non-hormonal options can include certain medication, minimally invasive surgery or major surgery such as a hysterectomy.

Medication

Your doctor may prescribe one or both of the following medications if you are experiencing heavy menstrual bleeding. These are typically used as first-line treatment options.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are painkillers generally available as over-the-counter medication. They are a suitable option for less severe heavy periods, and can help to reduce the amount of menstrual bleeding, particularly in the first few days of the cycle. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).2
  • Tranexamic acid works by blocking the breakdown of blood clots1. It can also help reduce menstrual blood loss and pain and only needs to be taken at the time of the bleeding. It has been shown to be more effective at relieving symptoms than NSAIDs.3,4 It may reduce the amount of blood flow during each period by 40-60%.5

Type | Non-Hormonal
Effectiveness | 40%
Timeframe | Short-term use

Advantages

  • NSAIDs are suitable for milder menorrhagia 2
  • NSAIDs can relieve painful menstrual cramps 11
  • NSAIDs and tranexamic acid only need to be taken at the time of bleeding
  • Tranexamic acid is more effective at relieving symptoms than NSAIDs 11
  • Some NSAIDs can reduce the amount of blood volume by up to 45% 2
  • Tranexamic acid is shown to reduce the amount of blood flow during each period by 40-60% 5

Disadvantages

  • NSAIDs and tranexamic acid are associated with gastrointestinal (GI) side effects, including nausea, vomiting, diarrhoea and dyspepsia, as well as disturbances in colour vision 2
  • Tranexamic acid can cause nausea and leg cramps 4
  • Patients on tranexamic acid also run the risk of developing deep venous thrombosis (DVT) 2

Minimally Invasive Surgery | Endometrial Ablation

Your doctor or gynaecologist may recommend a procedure called an endometrial ablation – a minimally invasive procedure performed as day surgery. It is mostly performed under general anaesthetic in Australia and New Zealand.

An endometrial ablation procedure involves removal of the lining of the uterus. It can greatly reduce or, in some cases, completely stop heavy menstrual bleeding.6

This procedure is intended for women who do not wish to have any (more) children in the future.

Because the treatment is associated with few side effects, women usually return to work or their daily activities the day after having the procedure.

Type | Non-Hormonal
Effectiveness | 90%
Timeframe | One-off procedure

Advantages

  • More than 9 in 10 women return to normal or lower than normal bleeding 6
  • Typically takes less than 5 minutes
  • Can be performed in the hospital or a day surgery unit
  • Local or general anaesthetic can be used (general is mostly used in Australia and New Zealand)
  • Can be done at any time during the cycle without hormonal pre-treatment
  • Recovery in 1 to 2 days
  • Removes lining but leaves uterus intact

Disadvantages

  • Only appropriate for women who do not want more children
  • Surgical risks associated with minimally invasive procedures
  • Cannot be reversed
  • After an ablation, your uterus is not able to properly support foetal development so some form of birth control is required

Major Surgery | Hysterectomy

In some cases your doctor may consider a hysterectomy the best option for you. It involves major surgery to remove the uterus and a longer recovery time (up to 8 weeks).

Hysterectomy is a permanent treatment option and is not generally recommended for first-line management unless less invasive options are unsatisfactory or inappropriate. Australian Clinical Care Standards suggests that therapeutic alternatives to hysterectomy should be consistently used across Australia for women with heavy menstrual bleeding where possible.1

Type | Non-Hormonal
Effectiveness | 100%
Timeframe | One-off Procedure

Advantages

  • Eliminates problem bleeding
  • Permanent

Disadvantages

  • Involves major invasive surgery
  • Risks of complications associated with major surgery
  • Requires general anaesthesia
  • 2 to 8 week recovery time
  • May result in early onset of menopause / possible need for future hormone treatment13
  • Cannot be reversed

Hormonal options

Hormonal options typically include the oral contraceptive pill or a hormonal intrauterine device (IUD).

Oral Contraceptives

Oral contraceptives – low doses of female hormones such as birth control pills (oestrogen and/or progestin) – can help regulate menstrual cycles and reduce excessive or prolonged menstrual bleeding as well as provide the added benefit of contraception.

They have been shown to reduce bleeding in around one-third of women treated for heavy periods, however, they may take up to 3 months before they start working.7

Type | Hormonal
Effectiveness | 33%
Timeframe | Long-term use

Advantages

  • Reduces bleeding in around one-third of patients7
  • Self-administered - taken by mouth
  • Contraceptive
  • Fertility restored when therapy is stopped

Disadvantages

  • May take up to 3 months before they start working13
  • About 50% of patients experience side effects7
  • Hormonal side effects can include depression, acne, headache, weight gain, breast tenderness, increased risk of cervical cancer14
  • Ongoing cost
  • Must remember to take them
  • 77% of women eventually progress to a surgical solution15

Hormone-Releasing Intrauterine Device or IUD

The Hormone-Releasing Intrauterine Device or IUD, which is inserted into the uterus, releases a steady amount of progestin called levonorgestrel. This makes the uterine lining thin and decreases menstrual blood flow to control heavy bleeding. It has been shown to reduce menstrual blood loss by 71-95% after 6 months.8

Clinical research shows 42% of women treated with an IUD opted for a hysterectomy after 5 years9. A hormone releasing IUD should be regularly removed and replaced every 5 years. It is not a permanent solution to heavy menstrual bleeding, but is an option for women still wanting to have children.

Type | Hormonal
Effectiveness | 40% after 5 years 9
Timeframe | Long-term use

Advantages

  • ~60% efficacy after 5 years9
  • Does not require taking pills
  • Contraceptive
  • Fertility restored when the IUD is removed

Disadvantages

  • Must be removed and replaced every 5 years
  • 70% of women experience intermenstrual bleeding/spotting9
  • 50% of women experience hormonal side effects16
  • Hormonal side effects may include: depression, acne, headaches, nausea, weight gain and hair loss8,16
  • Other potential side effects include abdominal pain, infection, and difficulty inserting the device, requiring cervical dilation17
  • May take up to 6 months before it starts working18
  • 42% of women require surgery within 5 years9

Note: Dilation and Curettage (D&C) is excluded from the treatment list due to its limited efficacy19. It is generally not offered as a treatment option in Australia and New Zealand.

 

References

1. Australian Commission on Safety and Quality in Health Care, Clinical Care Standards for Heavy Menstrual Bleeding, October 2017. 2. Panesar K, “Managing Menorrhagia”, US Pharmacist. 2011;36(9):56-61. 3.  Mayo Clinic. Tranexamic Acid. Available at www.mayoclinic.org/drugs-supplements/tranexamic-acid-oral-route/description/drg-20073517. Accessed February 2016. 4. PubMed Health, Informed Health Online. Treatment options for heavy periods, June 2013. Available at www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072477/. Accessed February 2016. 5. Munro M G, Abnormal Uterine Bleeding, Cambridge University Press. First published 2010. ISBN 978-0-521-72183-7. 6. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Gynecol Laparosc. 2002;9:418-428. 7. Cooper KG, et al. A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss. Br J Obstet Gynecol 1997;104:1360-66. 8. Mirena Product Information, 150601. 9. Hurskainen R, et al. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system of hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. JAMA 2004; 291:1456-1463. 10. Mayo Clinic. Tranexamic Acid. Available at www.mayoclinic.org/drugs-supplements/tranexamic-acid-oral-route/description/drg-20073517. Accessed February 2016. 2. Panesar K, “Managing Menorrhagia”, US Pharmacist. 2011;36(9):56-61. 11. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). Available at www.mayoclinic.org/diseases-conditions/menorrhagia/basics/treatment/con-20021959. Accessed February 2016. 13. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin: Endometrial Ablation. Obstet Gynecol 2007;109(5)1233-48. 14. Yasmin Prescribing Information. Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2007. 15. Cooper KG, Jack SA, Parkin DE, Grant AM. Five-Year Follow-up of Women Randomised to Medical Management or Transcervical Resection of the Endometrium for Heavy Menstrual Loss: Clinical and Quality of Life Outcomes. Br J Obstet Gynaecol. 2001;108(12):1222-1228. 16. Backman T, et al. Length of use and symptoms associated with premature removal of levonorgestrel intrauterine system: a nation-wide study of 17,360 users. BJOG 2000;107:335-9. 17. Istre O, e al. Treatment of menorrhagia with levonogestrol intrauterine system versus endometrial resection. Fertil Steril 2001. 18. Busfield RA, Farquhar CM, Sowter MC, et al. A Randomised Trial Comparing the Levonorgestrel Intrauterine System and Thermal Balloon Ablation for Heavy Menstrual Bleeding. BJOG. 2006;113(3):257-263. 19. Decherney AH, et al. Current Obstetric & Gynecologic Diagnosis & Treatment, ninth edition. New York, NY: McGraw-Hill Medical; 2003.