What is the best oral contraceptive to treat abnormal uterine bleeding?

Best Oral Contraceptive for Abnormal Uterine Bleeding

For abnormal uterine bleeding associated with ovulatory dysfunction, combined hormonal contraceptives with higher estrogen content are the preferred oral contraceptive treatment option. 1, 2

First-Line Treatment Options

Combined Hormonal Contraceptives (CHCs)

• Start with a combined oral contraceptive containing at least 30-35 mcg of ethinyl estradiol (higher estrogen content) 2, 3
• Higher estrogen content helps stabilize the endometrium and reduce breakthrough bleeding, though it may slightly increase thromboembolic risk 4
• For acute bleeding episodes, high-dose estrogen therapy can be used initially to control bleeding 5

Treatment Algorithm for Abnormal Uterine Bleeding

1. Initial approach: Start with a combined oral contraceptive containing 30-35 mcg ethinyl estradiol

2. If bleeding persists beyond 3 months:

   • Add a nonsteroidal anti-inflammatory drug (NSAID) during bleeding episodes 6, 3
   • Consider increasing estrogen content from 20 mcg to 35 mcg per day 3
   • Consider decreasing the hormone-free interval from seven to four or five days 3

3. If still ineffective:

   • Change to a different progestin formulation 6
   • Consider adding low-dose doxycycline 3

Alternative Options

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

• Most effective non-oral option for abnormal uterine bleeding 2
• Reduces menstrual blood loss by 40-50% and induces amenorrhea in many users 7
• Particularly beneficial for women with heavy menstrual bleeding and those with bleeding disorders 7, 2
• Typical failure rate of only 0.1-0.2% 7

Progestin-Only Methods

• Can be considered if estrogen is contraindicated
• Options include:
  • Progestin-only pills (norethindrone or drospirenone) 3
  • Depo-medroxyprogesterone acetate injections 6
  • Subdermal implants 6

Tranexamic Acid

• Non-hormonal option that can be used alone or with hormonal methods 2
• Particularly useful for heavy menstrual bleeding 2, 8

Important Considerations

Contraindications to Estrogen-Containing Contraceptives

• Cardiovascular disease with high risk of thromboembolic events 7
• Von Willebrand disease and other bleeding disorders 7
• History of venous thromboembolism 7

Common Pitfalls

• Failure to rule out structural causes: Before initiating hormonal treatment, ensure structural causes (polyps, adenomyosis, leiomyoma, malignancy) have been excluded 1, 2
• Inadequate counseling: Breakthrough bleeding is common during the first three months of oral contraceptive use; proper counseling can improve adherence 4, 6
• Overlooking compliance issues: Non-adherence to the prescribed regimen is a frequent cause of breakthrough bleeding 4
• Missing pregnancy as a cause: Always rule out pregnancy before initiating or continuing oral contraceptive use in cases of missed periods 4

Monitoring and Follow-up

• Assess response after 3 months of treatment 6
• If bleeding persists beyond 3 months despite treatment adjustments, consider further investigation (imaging, hysteroscopy) 1
• If medical treatment fails, is contraindicated, or not tolerated, surgical options including endometrial ablation and hysterectomy may be considered 1, 8