#377 How to slow the flow IV: Combined oral contraceptives
CLINICAL QUESTION
In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?
BOTTOM LINE
About 80% of women on COC will see improvement in mean blood loss, compared to 40% on placebo. Additionally, their use of sanitary items is reduced by approximately half (compared to 20% for placebo), and hemoglobin improves. Levonorgestrel-containing intrauterine systems, however, are more effective.
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EVIDENCE
- Three systematic reviews of randomized, controlled trials (RCTs) of COCs in the past 5 years.1-3 Focusing on most relevant.1 Results statistically different unless indicated.
- Versus placebo (2 industry-sponsored RCTs, 363 patients).1 After 6 months:
- Patient-assessed improvement in mean blood loss: 79% versus 42% (placebo).1
- Proportion with “response” (“menstrual normality” returns): 42% versus 3% (placebo).1
- Hemoglobin increase from baseline: ~6g/L versus ~1g/L (placebo).4,5
- Mean blood loss reduced by ~70% versus ~20% (placebo).4,5
- Sanitary item reduction: ~45% versus 20% (placebo).4,5
- Quality of life improvement: 56% versus ~30% (placebo).1
- Versus NSAIDs (1 RCT, 29 participants).1 At 2 months:
- Mean blood loss: No difference.
- Versus levonorgestrel-containing intrauterine devices (IUD) (2 RCTs, 151 participants).1 At 12 months:
- Treatment “success” (certain score on pictorial blood-loss assessment or no alternative treatment required): 60% versus 87% (IUD).1
- Mean blood loss reduced by ~35% versus ~85% (IUD).6
- Patient satisfaction: No difference.1
- Hemoglobin change: Inconsistent.6,7
- Quality of life: Inconsistent.
- Adverse effects: No difference.
- Versus vaginal ring (2 RCTs).1 At 6 months:
- Response, mean blood loss, patient satisfaction, hemoglobin: All no difference.
- New pragmatic RCT, 62 women IUD or COC.8 At 12 months:
- No difference in menorrhagia-related quality of life.
- Other systematic reviews found similar.2,3
- Limitations: Small number of participants, possible regression to the mean, various COC products studied, blinding not always performed, high drop-outs, some calculated means not reproducible by TFP authors.
CONTEXT
- Contraindications to COC include: Previous thromboembolism/cardiovascular disease/breast cancer, uncontrolled hypertension, smoking at age ≥35, migraine with aura, active liver/renal disease.9
- COCs may increase venous thromboembolism risk by 1/1250 women/year.10
- IUDs: most effective medication for reducing blood loss, likely at least as good as endometrial ablation.11
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good to know, also that NSAIDs are effective in achieving similar results re: blood loss
consistent with my clinical experience
Re affirm clinical practice.
confirmed what I knew
very good!
Fits with my experience
Ladder of therapy for benign premenopausal mennorhagia: Trial of NSAIDS—-Levonorgesterol IUD……endometrial ablation
I always negotiate with patient about options