From the Guidelines
Oral contraceptives are a highly effective treatment for menorrhagia, reducing heavy menstrual bleeding by thinning the uterine lining and stabilizing the endometrial lining. For heavy menstrual flow, monophasic combined oral contraceptives containing both estrogen and progestin are typically recommended, such as levonorgestrel/ethinyl estradiol or norethindrone/ethinyl estradiol 1. These can be taken in a standard 21/7 regimen or in extended/continuous regimens to reduce or eliminate periods altogether. According to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use, hormonal treatment with 20–30 μg ethinylestradiol combined oral contraceptives (COCs) or estrogen may improve bleeding irregularities, including menorrhagia 1.
Some key points to consider when prescribing oral contraceptives for menorrhagia include:
- The dose and type of oral contraceptive: 20–30 μg ethinylestradiol combined oral contraceptives (COCs) or estrogen are recommended 1
- The regimen: standard 21/7 or extended/continuous regimens can be effective 1
- Alternative options: progestin-only options like norethindrone or the levonorgestrel IUD can be effective alternatives if estrogen is contraindicated 1
- Potential side effects: nausea, breast tenderness, and spotting, particularly during the first few months of use 1
It's also important to note that other treatments, such as antifibrinolytic agents (e.g., tranexamic acid) and nonsteroidal anti-inflammatory drugs (NSAIDs), may also be effective in reducing heavy menstrual bleeding, but oral contraceptives are a highly effective and commonly recommended treatment option 1.
From the Research
Effects of Oral Contraceptives on Menorrhagia
The effects of oral contraceptives (OCs) on menorrhagia (heavy menstrual bleeding) have been studied in several trials. Here are the key findings:
- A study published in 2019 2 found that combined oral contraceptive pills (COCPs) improved response to treatment and lowered menstrual blood loss (MBL) when compared to placebo.
- The same study found that COCPs were less effective than the levonorgestrel-releasing intrauterine system (LNG IUS) in reducing MBL.
- A 2015 study 3 compared the effectiveness of the LNG IUS with oral medical therapy, including COCPs, and found that the LNG IUS was more effective in reducing HMB and improving quality of life.
- A 2009 study 4 found that there was no significant difference in menstrual blood loss between women treated with OCPS and those treated with other medical therapies, such as mefenamic acid or naproxen.
- An earlier study published in 2000 5 also found that the evidence was not sufficient to adequately assess the effectiveness of OCPS in reducing menorrhagia.
Key Findings
- COCPs can improve response to treatment and lower MBL when compared to placebo 2.
- COCPs are less effective than the LNG IUS in reducing MBL 2.
- The LNG IUS is more effective than oral medical therapy, including COCPs, in reducing HMB and improving quality of life 3.
- There is limited evidence to support the use of OCPS as a first-line treatment for menorrhagia 4, 5.
Comparison of Treatments
- COCPs vs. placebo: COCPs are more effective in improving response to treatment and lowering MBL 2.
- COCPs vs. LNG IUS: LNG IUS is more effective in reducing MBL and improving quality of life 3, 2.
- COCPs vs. other medical therapies: there is limited evidence to support the use of OCPS as a first-line treatment for menorrhagia 4, 5.