MJA: Wood, Box 4: Synopsis

Assessment

Ascertain blood loss by a pad and tampon count and determine any social or physical problems that heavy periods are causing. Greater understanding may prevent unnecessary treatment.
Dilatation and curettage should not be offered to women under the age of 35 as the risks outweigh the benefits. Endometrial sampling by catheter or hysteroscopy as an outpatient procedure is preferable in younger women.
Endometrial sampling by hysteroscopy as an outpatient procedure is likely to be the most cost-effective method of diagnosing uterine conditions in older women.
Vaginal ultrasonography is a useful diagnostic test in all women without an intact hymen.

Medical treatment

General practitioners should consider offering a course of the oral contraceptive pill or a non-steroidal anti-inflammatory drug as first-line treatment.
Tranexamic acid is more effective in the short term, but its long term safety has not been established, making it a second-line treatment. Norethisterone from Days 5 to 26 of the menstrual cycle may be a suitable alternative second-line treatment, although further controlled trials to establish its comparable efficacy are required.
A progesterone-impregnated IUD may become the most appropriate treatment for reducing menstrual blood loss (providing government approval is obtained).
Drugs are unlikely to help women with severe menstrual bleeding (> 250 mL), and are less likely to reduce bleeding in the presence of uterine disease.

Surgical treatment

There is no obvious best surgical treatment. The advantages of endometrial resection over hysterectomy for menorrhagia in women with a normal uterus may not be sustained in the longer term and the patient's choice of procedure is important.
Dilatation and curettage should not be used as treatment for menorrhagia.
Hysterectomy is the procedure of choice for patients with an enlarged uterus, severe endometriosis, failed endometrial resection, increased risk of uterine cancer or who want to be guaranteed a cure. Hysterectomy may be performed by an abdominal, vaginal or laparoscopic technique.
Polyps, myomas, adenomyomas and ovarian disease causing menorrhagia may be dealt with by hysteroscopic, laparoscopic or abdominal surgery (endometrial resection, polypectomy, myomectomy, adenomyomectomy or hysterectomy).