Contraceptive Regimens for Dysfunctional Uterine Bleeding
The most effective first-line contraceptive regimen for dysfunctional uterine bleeding is the levonorgestrel intrauterine device (LNG-IUD), followed by combined hormonal contraceptives with tranexamic acid if needed. 1
First-Line Options
Levonorgestrel Intrauterine Device (LNG-IUD)
- Highly effective for treating dysfunctional uterine bleeding
- Provides both contraception and treatment for heavy menstrual bleeding
- According to the International Society on Thrombosis and Haemostasis, 19% of clinicians recommend LNG-IUD as first-line therapy for persistent heavy menstrual bleeding 1
- Offers long-term management with minimal systemic effects
Combined Oral Contraceptives (COCs)
- Effective for anovulatory bleeding through endometrial stabilization
- Mechanism: Suppression of gonadotropins, inhibition of ovulation, changes in cervical mucus and endometrium 2
- For persistent heavy menstrual bleeding despite COCs, adding tranexamic acid (TXA) is recommended by 53% of specialists 1
- Consider increasing estrogen content from 20mcg to 35mcg for better bleeding control 3
- May decrease hormone-free interval from 7 to 4-5 days to improve cycle control 3
Second-Line Options
If first-line treatment fails to control bleeding:
Combined Approaches
- LNG-IUD insertion (recommended by 51% of specialists when COCs fail) 1
- COCs combined with tranexamic acid (13% of specialists) 1
- COCs with DDAVP (desmopressin) (13% of specialists) 1
Alternative Delivery Methods
- Intravaginal ring (Nuvaring®) - releases 15μg ethinyl estradiol and 120μg etonogestrel daily
- As effective as COCs in controlling heavy menstrual bleeding
- Better cycle control and higher continuation rates compared to COCs
- Avoids gastrointestinal absorption and hepatic first-pass metabolism 4
Third-Line Options
For refractory cases:
- Combined DDAVP/COC/TXA (34% of specialists recommend) 1
- DDAVP with COCs (14% of specialists) 1
- DDAVP with TXA (13% of specialists) 1
Progestin-Only Options
Progestin-Only Pills
- Effective for anovulatory dysfunctional uterine bleeding
- Medroxyprogesterone acetate: 10mg daily for 10 days each month for ≥3 months (for adolescents) 5
- For reproductive age women: oral medroxyprogesterone acetate 10 days each month for 6 months 5
- Norethisterone (5-10mg 3 times daily) from days 12-25 for anovulatory women and days 5-25 for ovulatory women 6
- Consider switching from norethindrone to drospirenone progestin-only pills for better bleeding control 3
Injectable Progestins
- Depo-medroxyprogesterone acetate (DMPA)
- For abnormal bleeding with DMPA, consider adding COCs or NSAIDs 3
Progestin Implants
- For abnormal bleeding with implants, COCs or NSAIDs may be used 3
Important Considerations
- Rule out other causes of abnormal uterine bleeding before attributing to dysfunctional etiology
- Verify correct placement of LNG-IUD if this method is chosen and bleeding persists 3
- NSAIDs are effective first-line treatment for abnormal bleeding with LNG-IUD; estradiol can be added if NSAIDs are ineffective 3
- Tranexamic acid is the most effective medical therapy for dysfunctional uterine bleeding 7
- Counsel patients about potential for abnormal bleeding at initiation of any hormonal contraceptive method 3
Special Populations
Perimenopausal Women
- Cyclic progestin or cyclic conjugated equine estrogens for 25 days with medroxyprogesterone acetate for days 18-25 5
- Low-dose combination oral contraceptives for non-smokers without vascular disease 5
- Progestin-only methods are safer alternatives for women over 35 with contraindications to combined hormonal methods 8
Women with Bleeding Disorders
- For women with bleeding disorders of unknown cause experiencing heavy menstrual bleeding despite COCs, adding tranexamic acid is recommended as first-line treatment 1