What progesterone (hormone) regimen is effective for treating heavy menstrual bleeding?

Progesterone Regimens for Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine device (LNG IUS) is the most effective progesterone-based treatment for heavy menstrual bleeding, resulting in 71-95% reduction in menstrual blood loss. 1

First-Line Treatment Options

• The levonorgestrel 20 μg/d-releasing intrauterine device is the most effective progesterone-based approach for heavy menstrual bleeding, with efficacy comparable to endometrial ablation 1
• The LNG IUS works primarily at the endometrial level with minimal systemic absorption, making it safer for patients with cardiovascular concerns 1
• For patients without cardiovascular risk factors, combined oral contraceptives with 30-35 μg ethinyl estradiol can be used as first-line treatment for heavy menstrual bleeding 2
• The LNG IUS has been shown to be more effective than oral medications in reducing menstrual blood loss as measured by both objective methods and patient-reported outcomes 3

Second-Line Treatment Options

• Cyclic oral progestin treatment (days 5-26 of the menstrual cycle) has been found to reduce bleeding by approximately 87%, though less effectively than the LNG IUS 1
• For women who cannot use or decline the LNG IUS, oral progestins are an alternative, though they result in more irregular bleeding patterns 4
• Depot Medroxyprogesterone Acetate (DMPA) can be used as a second-line treatment for heavy menstrual bleeding, as it suppresses circulating androgen levels and pituitary gonadotropin levels 2, 5
• High-dose oral or injectable progestin-only medications may be considered for short-term use in hemodynamically unstable women with uncontrolled bleeding 1

Specific Regimens and Their Efficacy

• Levonorgestrel IUD (20 μg/day): 71-95% reduction in menstrual blood loss, highest patient satisfaction and continuation rates 1, 3
• Lower-dose levonorgestrel IUD (14 μg/day): May offer advantages for patients with cardiovascular concerns due to lower hormonal absorption 1
• Cyclic oral progestins (days 5-26): 87% reduction in bleeding but higher discontinuation rates compared to LNG IUS 1, 4
• Medroxyprogesterone acetate: Inhibits pituitary gonadotropin secretion, preventing follicular maturation and ovulation, but not recommended for dysfunctional uterine bleeding due to unpredictable withdrawal bleeding 5

Special Considerations

• For patients with cardiovascular disease (especially SCAD), the LNG IUS is preferred over systemic hormonal treatments due to minimal systemic absorption 1, 6
• NSAIDs and tranexamic acid should be avoided in women with cardiovascular disease due to their association with MI and thrombosis 1
• For patients with hemodynamic instability or severe bleeding (saturating a large pad/tampon hourly for ≥4 hours), urgent evaluation is warranted 1
• If bleeding persists despite LNG IUS or oral progestins, second-generation endometrial ablation techniques may be considered as they have greater long-term efficacy than oral medical treatment 1

Monitoring and Follow-up

• All reproductive-age women with abnormal uterine bleeding should be tested for pregnancy before initiating treatment 1
• Monitor for minor adverse effects with LNG IUS, which may include pelvic pain, breast tenderness, and ovarian cysts 3
• Patients using cyclic oral progestins should be advised that irregular bleeding patterns are common, especially in the first few months 4
• The benefits and risks of continuing or discontinuing hormonal therapy should be reviewed periodically 1

Common Pitfalls and Caveats

• Oral progestins are significantly less effective than the LNG IUS and have higher discontinuation rates 3, 4
• Medroxyprogesterone acetate is not recommended for dysfunctional uterine bleeding due to difficulty in predicting withdrawal bleeding timing 5
• Frequent intermenstrual bleeding and spotting is likely during the first few months after commencing LNG IUS treatment 3, 7
• Combined hormonal contraceptives increase the risk of venous thromboembolism three to fourfold and should be avoided in women with cardiovascular disease 2, 6