Birth Control Pills for Heavy Menstrual Bleeding
Yes, birth control pills (oral contraceptive pills) are an effective treatment option for heavy menstrual bleeding (menorrhagia) and should be considered after ruling out structural causes of bleeding. 1
Treatment Algorithm for Heavy Menstrual Bleeding
First-Line Options:
- Levonorgestrel-releasing intrauterine system (LNG-IUS) - Most effective medical treatment for heavy menstrual bleeding, reducing blood loss by 71-95% 1, 2
- Combined hormonal contraceptives (CHCs) - Second-line option when LNG-IUS is not suitable 2
Mechanism of Action for CHCs in Treating Heavy Bleeding:
- Induce regular shedding of a thinner endometrium
- Inhibit ovulation
- Provide endometrial stabilization 3
Effectiveness of Birth Control Pills:
- Moderate-quality evidence shows CHCs can increase successful treatment from 3% to 77% in women with unacceptable heavy menstrual bleeding 4
- E2V/DNG (estradiol valerate/dienogest) combination has shown a 65% reduction in mean blood loss after six months 3
- Approximately half of women using E2V/DNG demonstrate an 80% reduction in mean blood loss 3
Clinical Considerations
Patient Selection:
- Rule out structural causes (polyps, fibroids) before initiating hormonal therapy 1
- Consider cardiovascular risk factors before prescribing CHCs 5
- Avoid in women with:
- Uncontrolled hypertension
- History of thromboembolism
- Liver disease
- Migraines with aura 5
Monitoring:
- Annual visit with healthcare provider for blood pressure check 5
- Monitor for side effects including:
- Breakthrough bleeding (common in first 3 months)
- Headaches
- Breast tenderness 5
Management of Breakthrough Bleeding:
- Common in first 3-6 months of use
- If bleeding persists after 3 months or occurs after previously regular cycles, rule out pregnancy or malignancy 5
- 8-25% of women may experience unscheduled bleeding per 28-day cycle 5
Alternative Options When CHCs Are Contraindicated
For women with SCAD (Spontaneous Coronary Artery Dissection) or other cardiovascular conditions where estrogen is contraindicated:
- Progestin-only options may be considered 1
- Levonorgestrel-releasing IUD is particularly beneficial as it works primarily at the endometrial level with minimal systemic effects 1
Practical Advice
- Start with a monophasic CHC containing 30-35 μg of ethinyl estradiol
- Counsel patients about expected bleeding patterns and potential side effects
- Reassure patients that bleeding irregularities during the first 3-6 months are common and generally not harmful 1
- Consider hematologic parameters - CHCs can improve hemoglobin, hematocrit, and ferritin levels in women with heavy menstrual bleeding 3
The evidence supports that combined oral contraceptives are an effective option for treating heavy menstrual bleeding while also providing contraception, though they are less effective than the LNG-IUS 2, 4.