What are the alternative options for a patient experiencing menorrhagia (heavy menstrual periods) while on Hailey Fe 1.5/30 (ethinyl estradiol/norethindrone acetate)?

Management Options for Heavy Menstrual Bleeding While on Hailey Fe 1.5/30

For a patient experiencing heavy menstrual bleeding while on Hailey Fe 1.5/30 (ethinyl estradiol/norethindrone acetate), switching to a higher estrogen dose combined hormonal contraceptive or a levonorgestrel intrauterine system would be the most effective next option.

Initial Assessment

• Rule out underlying gynecological problems such as:

  • Interactions with other medications 1
  • Sexually transmitted diseases 1
  • Pregnancy 1
  • Pathologic uterine conditions (e.g., fibroids, polyps) 1

• Evaluate for anemia from blood loss, including serum ferritin 2

Treatment Options

First-Line Options

• Levonorgestrel Intrauterine System (LNG-IUD)

  • Superior effect on heavy menstrual bleeding compared to oral contraceptives 3
  • Provides local hormone delivery with minimal systemic effects 1
  • Significantly reduces menstrual blood loss 1
  • Safe and effective in patients with bleeding disorders 3

• Higher Estrogen Dose Combined Hormonal Contraceptive

  • Consider switching to a formulation with higher estrogen content 1
  • Can be used for short-term treatment (10-20 days) for acute heavy bleeding 1
  • Provides contraception while treating menorrhagia 4

Additional Medical Options

• NSAIDs for short-term treatment (5-7 days)

  • Can reduce menstrual blood loss by 20-60% 5
  • Use during days of bleeding 1
  • Examples include mefenamic acid, which has shown significant cessation of bleeding within 7 days 1

• Tranexamic acid

  • Non-hormonal alternative that may reduce bleeding symptoms 1
  • Can reduce menstrual blood loss by 20-60% 5
  • Available in oral and intravenous forms for acute bleeding 2

Treatment Algorithm

1. If no underlying gynecological problem is found:

   • First option: Switch to levonorgestrel IUD 1, 3
   • Second option: Switch to a higher estrogen dose combined hormonal contraceptive 1
   • Third option: Add NSAIDs during days of bleeding while continuing current contraceptive 1

2. If heavy bleeding persists despite these measures:

   • Consider adding tranexamic acid during days of bleeding 1, 2
   • Counsel on alternative contraceptive methods if bleeding remains unacceptable 1

3. If an underlying gynecological problem is found:

   • Treat the specific condition or refer for care 1
   • For fibroids: Consider GnRH agonists or antagonists if appropriate 1

Important Considerations

• Bleeding irregularities are common with hormonal contraceptives but are generally not harmful 1

• Enhanced counseling about expected bleeding patterns has been shown to reduce method discontinuation 1

• The presence of clots ≥1 inch diameter, low ferritin, and "flooding" (changing pad/tampon more frequently than hourly) may indicate an underlying bleeding disorder requiring hematology consultation 6, 2

• Surgical options should be reserved for those who do not respond to medical therapy 2