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 & SMFM Guidance on the Use of IUDs and Contraceptive Implants

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