BACKGROUND AND PURPOSE:

• Lethaby et al. (Cochrane Database Syst Rev., 2019) sought to determine the efficacy of combined hormonal contraceptives for the treatment of heavy menstrual bleeding (HMB)

METHODS:

• Systematic review and meta-analysis
• Included studies: RCTS that assessed combined hormonal contraceptives for HMB
  • Participants
    • Regular menses | Reproductive age group
  • Combined oral contraceptives included
    • Combined oral contraceptive pill (OCP) | Contraceptive vaginal ring | Patch
  • Alternatives included
    • No treatment | Placebo | Other medical therapies
• Primary outcomes
  • Treatment success (mostly assessed via Pictorial Blood Loss Assessment Chart [PBAC] score < 100) | Menstrual blood loss (MBL) | Participant satisfaction
• Secondary outcomes
  • Adverse events | Quality of life | Hemoglobin level
• GRADE methods used to assess quality of evidence

RESULTS:

• 8 RCTs | 805 participants
• Quality level of the studies
  • The only two trials comparing OCPs with placebo were of moderate quality (e.g., lack of blinding in some of the other studies)
• No RCTs regarding patch were available
• 2 studies compare COCP to vaginal ring
• Comparators included
  • Placebo | Mefenamic acid | Naproxen | LNG-IUS (hormonal IUD) | Danazol | Progestogen (norethisterone acetate)
• OCPs were not all the same dose
  • Ethinyl estradiol 30 ug/levonorgestrel 150 ug
  • Ultra-low dose ethinyl estradiol 20 ug/desogestrel 120 ug
  • Ethinyl estradiol 20 ug/NETA 1 mg
  • ‘Step-up/step-down’ (multiphasic): Estradiol valerate(E2V) 3 mg on days one to two; E2V 2 mg + DNG 2 mg on days three to seven; E2V 2 mg + DNG 3 mg on days eight to 24; E2V 1 mg on days 25 to 26; and placebo on days 27 to 28
• Comparing OCPs to placebo (2 studies both used multiphasic regimen) there was
  • Improved response to treatment (return to menstrual ‘normality’)
    • Odds ratio (OR) 22.12 (95% CI 4.40 to 111.12; moderate-quality evidence)
  • Reduced MBL
    • OR 5.15 (95% CI 3.16 to 8.40; moderate-quality evidence)
  • More minor adverse events, especially breast pain
• Comparing OCPs to NSAIDs (Mefenamic acid | Naproxen)
  • Insufficient evidence to determine reduction in MBL
• Comparing OCPs to LNG-IUS
  • LNG-IUS was more effective in reducing MBL
    • OR 0.21 (95% CI 0.09 to 0.48; low-quality evidence)
• Comparing vaginal ring to the following
  • OCPs: No evidence of a benefit for one treatment compared to the other, with greater likelihood of nausea with OCPs
  • Progestogens: Vaginal ring may increase odds of satisfaction but not clear if there is benefit in MBL reduction (small ‘n’)

CONCLUSION:

• Combined OCPs were effective over 6 months in reducing HMB
• LNG-IUS is more effective than OCP for reducing HMB
• Data limited regarding comparisons with vaginal ring, NSAIDs and long acting progestogens

Learn More – Primary Sources:

Combined hormonal contraceptives for heavy menstrual bleeding

Related ObG Topics:

Hormonal Contraception Benefits – Beyond Pregnancy Prevention

CDC Guidelines on How to Start Combined Hormonal Contraceptives

ACOG Releases Practice Bulletin on the Use of IUDs and Contraceptive Implants

Are We Meeting the ACOG Screening Guidelines for Von Willebrand Disease in Adolescents with Menorrhagia?