#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.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
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
Latest Tools for Practice
#379 Bumpin’ Up the Protection? RSV Vaccine in Pregnancy
How effective and safe is the respiratory syncytial virus (RSV) vaccine (AbrysvoTM) when given during pregnancy?
#378 Tony Romo-sozumab: Winning touchdown in osteoporosis or interception for the loss?
What is the efficacy and safety of romosozumab in postmenopausal women with osteoporosis?
#377 How to slow the flow IV: Combined oral contraceptives
In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?
good to know, also that NSAIDs are effective in achieving similar results re: blood loss
consistent with my clinical experience
confirmed what I knew
very good!
Fits with my experience