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Grand Rounds

How Do Combined Hormonal Contraceptives Compare to Other Treatments for Menorrhagia?

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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

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Related ObG Topics:

Practical info for your gynecology practice
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?

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