Nonsurgical treatment options for heavy menstrual bleeding

Treatment options for heavy menstrual bleeding depend on the uterine anatomy, the women's preferences and personal ideas, her age and her future child wish. If the uterus has a normal anatomy, treatment options include hormonal or non-hormonal drugs (including levonorgestrel releasing intra-uterine systems; LNG-IUS), endometrial ablation and hysterectomy. In general, the main advantage of pharmacological treatment is the reversibility and therefore the eligibility for women, independent of age and future child-wish. This article provides a literature review on the effectiveness of medical treatment (hormonal and non-hormonal) for heavy menstrual bleeding and to discuss the dilemmas experienced by women and doctors. A literature search was performed focusing on the effectiveness of hormonal and non-hormonal medical treatment of women suffering from heavy menstrual bleeding. For nonsteroidal anti-inflammatory drugs (NSAIDs) as well as tranexamic acid, direct evidence for comparison to placebo is available, for the other agents (oral progestins (luteal phase and long term); LNG-IUS; combined hormonal contraceptives (combined oral contraceptive pills, combined vaginal ring), evidence could be extracted from a recent network meta-analysis. Evidence on treatment effects on HMB of the progesterone only pill and the etonogestrel subdermal implant is lacking. LNG-IUS appears to be the best pharmacological treatment option for HMB in terms of reducing blood loss as well as improving symptoms. Professionals should be aware that a number of women want to avoid a hormone-containing treatment, this may be due to (expected) negative side effects. In conclusion, considering pharmacological treatment of HMB without underlying pathology, LNG-IUS seems to be the best option to reduce menstrual blood loss. However, it is advised to carefully listen what women want, think and believe and to make a shared tailor-made decision. Pharmacological treatment for HMB should be initiated as a surgical intervention can be avoided. However, women who are not receptive to first-line drug treatments should be given the opportunity to improve their quality of life by getting rid of disabling symptoms of heavy menstrual bleeding, by offering treatment with endometrial ablation or hysterectomy.