Menorrhagia, mechanisms and targeted therapies

Efficient treatment options for the increasing complaint of heavy menstrual bleeding are required to avoid the morbidity associated with major surgery. This review summarizes recent developments in the nonsurgical approach to treating menorrhagia. Even though the mechanism of menstruation has still not been fully elucidated, there have been promising developments in the attempt to reduce menstrual blood loss. The levonorgestrel-releasing intrauterine system has proven very efficient, and there is a frameless device suitable for enlarged uterine cavities. The side effect of breakthrough bleeding has been the main reason for discontinuing treatment. Recent studies have investigated options of concomitant therapy with antiprogestogens to counter this effect. Another group of novel compounds are selective progesterone receptor modulators, which thus far have been shown to reduce menstrual bleeding without the unwanted effect of unscheduled bleeding episodes. As menorrhagia is largely a subjective complaint, it is important for successful therapy to be based on an informed patient's choice. Currently, lack of evidence-based practice, poor compliance and unpleasant side effects limit the success of medical therapies contributing to the amount of major surgery performed for this indication. If concomitant therapies succeeded in minimizing the episodes of breakthrough bleeding with the levonorgestrel-releasing intrauterine system, its recommendation as a first choice treatment may be confounded. Further research is needed into efficiency and safety of selective progesterone receptor modulators, which appear to have great potential in reducing menstrual blood loss.