#287 How to Slow the Flow: NSAIDs for Heavy Menstrual Bleeding
CLINICAL QUESTION
In premenopausal heavy menstrual bleeding without pathological cause, do nonsteroidal anti-inflammatory drugs (NSAIDs) improve patient outcomes?
BOTTOM LINE
Based on low-quality evidence, NSAIDs reduce relative mean menstrual blood loss by ~30%, and ~20-50% fewer sanitary products used than placebo. Effects on bleeding duration are inconsistent.
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EVIDENCE
Focused on randomized, placebo-controlled trials (RCTs). Menorrhagia, when defined: >80ml/cycle.
Naproxen: 2 cross-over RCTs, 4 patients each. Baseline blood loss ~140ml. After 2 menstrual cycles of each treatment:1-3
- Mean blood loss decreased ~30% over placebo.1-3
- In 1 RCT, 79% felt naproxen better than placebo.3
- No effect on bleeding duration.3
- Ibuprofen 1200mg/day decreased mean blood loss ~25% over placebo.
- Ibuprofen 600mg/day: not different from placebo.
- No effect bleeding duration.
- Largest RCT: 80 women, 3 consecutive cycles.5
- “Relief” of menorrhagia (not defined): 86% versus 20%, number needed to treat=2.
- Number of pads per day: 15 at baseline, 7 on mefenamic acid (placebo not stated).
- Number of bleeding days: 10 at baseline, 4 on mefenamic acid (placebo not stated).
- 3 RCTs (2 cross-over, total 49 patients): mefenamic acid better than placebo.
- Mean blood loss ~10-40% lower than placebo.6-8
- “Responded” (not defined): 79% versus 18% (placebo).6,9
- 1 cross-over RCT, 15 patients: no difference in blood loss.10
- 1 RCT, 68 women, only 1 completed all study follow-up.11
- Median number of pads used (baseline unknown): 21 versus 10 (diclofenac).
- Number of bleeding days (baseline unknown): 6 versus 4 (diclofenac).
- 1 cross-over RCT, 35 women.12
- Both groups decreased mean blood loss ~47% from baseline.
- Days of bleeding in both groups decreased 0.8.
- Number of tampons decreased from ~31 at baseline to ~24.
- Volume of blood loss does not correlate with patient experience.13
- NSAIDs are used immediately before and during menses (example: mefenamic acid 500mg TID from menstruation onset to end6).
- Mefenamic acid costs ~$20/cycle; naproxen and ibuprofen ~$4 each.14-16
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