Medication Summary
Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.
Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.
Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.
Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.
Nonsteroidal anti-inflammatory drugs
Class Summary
Block formation of prostacyclin, an antagonist of thromboxane, which is a substance that accelerates platelet aggregation and initiates coagulation. Prostacyclin is produced in increased amounts in menorrhagic endometrium. Because NSAIDs inhibit blood prostacyclin formation, they might effectively decrease uterine blood flow.
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Diclofenac (Cataflam)
Inhibits PG synthesis by decreasing activity of enzyme cyclooxygenase, which in turn decreases formation of PG precursors.
Combination oral contraceptives
Class Summary
OCPs containing estrogen and progestin used to treat acute hemorrhagic uterine bleeding.
Dienogest/estradiol valerate (Natazia)
Negative feedback decreases GnRH amounts resulting in reduced LH and FSH secretion from the pituitary gland and anovulation. Indicated for treatment of heavy menstrual bleeding not caused by any diagnosed conditions of the uterus in women who choose an oral contraceptive for contraception.
Progestins
Class Summary
Occasional anovulatory bleeding that is not profuse or prolonged can be treated with progestins, antiestrogens given in pharmacologic doses. Inhibit estrogen-receptor replenishment and activate 17-hydroxysteroid dehydrogenase in endometrial cells, converting estradiol to the less-active estrone.
Medroxyprogesterone (Depo-SubQ Provera 104, DepoProvera, MPA)
Short-acting synthetic progestin. Works as an antiestrogen by minimizing estrogen effects on target cells. Endometrium is maintained in an atrophic state. Effective against hyperplasia and has modest effects on serum lipids (ie, lowering HDL).
Megestrol (Megace, Megace ES)
It is active against uterine hyperplasia without significantly altering serum lipid levels.
Levonorgestrel intrauterine (Liletta, Mirena)
Indicated for heavy menstrual bleeding for up to 5 years in women who choose to use intrauterine contraception as a method of contraception.
Gonadotropin-releasing hormone agonists
Class Summary
Work by reducing concentration of GnRH receptors in the pituitary via receptor down-regulation and induction of postreceptor effects, which suppress gonadotropin release. After an initial gonadotropin release associated with rising estradiol levels, gonadotropin levels fall to castrate levels, with resultant hypogonadism. This form of medical castration is very effective in inducing amenorrhea, thus breaking the ongoing cycle of abnormal bleeding in many anovulatory patients.
Leuprolide (Lupron)
Suppresses ovarian and testicular steroidogenesis by decreasing LH and FSH levels.
Androgens
Class Summary
Certain androgenic preparations have been used historically to treat mild-to-moderate bleeding, particularly in ovulatory patients with abnormal uterine bleeding. Use might stimulate erythropoiesis and clotting efficiency. Alters endometrial tissue so that it becomes inactive and atrophic.
Danazol (Danocrine)
Synthetic steroid analog with strong antigonadotropic activity (inhibits LH and FSH) and weak androgenic action. Competes with androgen and progesterone at receptor level, resulting in amenorrhea within 3 mo.
Arginine vasopressin derivatives
Class Summary
Indicated in patients with thromboembolic disorders.
Desmopressin (DDAVP)
Has been used to treat abnormal uterine bleeding in patients with coagulation defects. Transiently elevates factor VIII and von Willebrand factor.
Estrogens
Class Summary
Effective in controlling acute, profuse bleeding. Exerts a vasospastic action on capillary bleeding by affecting the level of fibrinogen, factor IV, and factor X in blood and platelet aggregation and capillary permeability. Estrogen also induces formation of progesterone receptors, making subsequent treatment with progestins more effective.
Conjugated equine estrogen (Premarin)
Only controls bleeding acutely but does not treat underlying cause. Appropriate long-term therapy can be administered once the acute episode has passed.
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Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.
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Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.
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Flow chart continued from the previous image.
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Flow chart continued from the previous 2 images.
