What are the oral contraceptive options for managing heavy menstrual cycles, comparing combined oral contraceptives (COCs) and progestin-only pills (POPs)?

From the Guidelines

For managing heavy menstrual cycles, combined oral contraceptives (COCs) are generally more effective than progestin-only pills (POPs). COCs containing ethinyl estradiol (20-35 mcg) combined with progestins like levonorgestrel, norethindrone, or drospirenone can reduce menstrual blood loss by 40-50% 1. Monophasic formulations taken continuously or in extended cycles (skipping placebo pills) provide the best results. Common options include Loestrin, Yaz, or Seasonique. These work by thinning the endometrial lining and stabilizing it, preventing excessive buildup and shedding.

Key Differences Between COCs and POPs

• COCs are more effective in reducing menstrual blood loss
• COCs have a more predictable bleeding pattern compared to POPs
• POPs are safer for women with contraindications to estrogen, such as history of blood clots, migraines with aura, hypertension, or smoking over age 35 1

Treatment Considerations

• Treatment should continue for at least 3 months to evaluate effectiveness
• Side effects of COCs include nausea, breast tenderness, and headaches, which typically improve after 2-3 months of use
• For severe bleeding unresponsive to oral contraceptives, additional evaluation for underlying conditions may be necessary, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions (such as fibroids or polyps) 1

Alternative Treatment Options

• NSAIDs for short-term treatment (5–7 days)
• Hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days)
• If heavy or prolonged bleeding persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods, and offer another method if it is desired 1

From the FDA Drug Label

ALL ORAL CONTRACEPTIVES Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease

The main oral contraceptive options for managing heavy menstrual cycles are:

• Combined Oral Contraceptives (COCs): These contain both estrogen and progestin, and can help reduce menstrual bleeding by thinning the uterine lining.
• Progestin-Only Pills (POPs): These contain only progestin, and can help reduce menstrual bleeding by thinning the uterine lining, but may cause more irregular bleeding than COCs.

Key differences between COCs and POPs include:

• Estrogen content: COCs contain estrogen, while POPs do not.
• Bleeding patterns: COCs tend to produce more regular bleeding, while POPs may cause more irregular bleeding.
• Thromboembolic risk: COCs with higher estrogen content may increase the risk of thromboembolic disease.

When choosing an oral contraceptive for heavy menstrual cycles, it is essential to consider the individual patient's needs and medical history, and to discuss the potential benefits and risks with a healthcare provider 2, 3, 4.

From the Research

Oral Contraceptive Options for Heavy Menstrual Cycles

Oral contraceptive options are available for managing heavy menstrual cycles, including combined oral contraceptives (COCs) and progestin-only pills (POPs). The following points compare and contrast these options:

• Combined Oral Contraceptives (COCs): COCs are effective in reducing heavy menstrual bleeding (HMB) by inducing a regular shedding of a thinner endometrium and inhibiting ovulation 5. They are also a reliable and acceptable form of contraception, with excellent cycle control and a low incidence of irregular bleeding 6.
• Progestin-Only Pills (POPs): While there is limited evidence on the effectiveness of POPs in reducing HMB, they may be a suitable option for women who cannot use COCs due to certain medical conditions or side effects 5.
• Comparison of COCs and POPs: There is insufficient evidence to determine the comparative efficacy of COCs and POPs in reducing HMB 5. However, COCs have been shown to be more effective than some other medical therapies, such as non-steroidal anti-inflammatory drugs (NSAIDs) 5.
• Benefits and Risks: COCs offer several additional health benefits, including a decrease in the risk of ovarian cancer, endometrial cancer, and colorectal cancer, as well as treatment for dysmenorrhea, hirsutism, and acne vulgaris 7. However, they also carry an increased risk of venous thromboembolism and arterial thrombosis 7.
• Prescribing Patterns and Compliance: Prescribers should provide thorough and balanced information on the benefits and risks of COCs to ensure optimal compliance and continuation rates 7. Poor compliance and discontinuation are significant problems, and it is crucial to address these issues to maximize the effectiveness of COCs.

Key Findings

• Moderate-quality evidence suggests that COCs reduce HMB in women with unacceptable HMB from 12% to 77% (compared to 3% in women taking placebo) 5.
• COCs are less effective than the levonorgestrel-releasing intrauterine system (LNG IUS) in reducing HMB 5.
• Limited evidence suggests that COCs and the contraceptive vaginal ring (CVR) have similar effects on HMB 5.
• The net effect of the additional health effects of COC use may be positive, with a slight increase in life expectancy 7.