What oral contraceptive, such as Yasmin (drospirenone and ethinyl estradiol), do you recommend for a patient with menorrhagia?

Recommendation for Oral Contraceptive in Menorrhagia

For a patient with menorrhagia, I recommend switching to a combined oral contraceptive containing drospirenone 3 mg and ethinyl estradiol 20 μg in a 24/4 regimen. 1, 2

Rationale for Selection

• Progestin-only contraceptives are first-line options for menorrhagia but combined oral contraceptives containing drospirenone have specific advantages for heavy menstrual bleeding 1, 2
• Drospirenone has antimineralocorticoid properties that reduce fluid retention and bloating, which are common concerns with menorrhagia 3
• The 24/4 regimen (24 active pills, 4 placebo) provides more stable hormone levels and fewer hormone-free days, resulting in better bleeding control compared to traditional 21/7 regimens 4, 3
• Studies show that drospirenone-containing oral contraceptives significantly reduce the number of bleeding days by approximately one-third compared to standard regimens 4

Efficacy for Menorrhagia

• Drospirenone 3 mg/ethinyl estradiol 20 μg has demonstrated effectiveness in reducing menstrual flow and associated symptoms 3, 5
• The lower estrogen dose (20 μg) maintains efficacy while potentially reducing estrogen-related side effects 6
• Clinical trials show significant reduction in menorrhagia, intermenstrual bleeding, and dysmenorrhea with drospirenone-containing contraceptives 4, 7
• Extended regimen options (84/7) may be considered for patients with severe symptoms, as they further reduce the total number of bleeding days 4

Safety Considerations

• NSAIDs should be considered as first-line treatment for 5-7 days during bleeding episodes before initiating hormonal therapy 2
• Estrogen-containing contraceptives should be avoided in women at high risk of thromboembolic events (e.g., cyanosis, Fontan physiology, mechanical valves, prior thrombotic events, pulmonary arterial hypertension) 1
• Common side effects include nausea, intermenstrual bleeding, and breast pain, but these typically improve after the first few cycles 6, 5
• Thorough assessment to rule out underlying pathology (fibroids, polyps, STIs, pregnancy) is essential before initiating hormonal therapy 2

Alternative Options

• If combined hormonal contraceptives are contraindicated, consider:
  • Progestin-only pills which have fewer thromboembolic risks 1
  • Levonorgestrel intrauterine system which provides excellent control of menorrhagia with minimal systemic effects 1
  • Tranexamic acid during menstruation, which can reduce bleeding by inhibiting fibrinolysis 1

Monitoring and Follow-up

• Counsel the patient about expected bleeding patterns, including potential breakthrough bleeding in the first 2-3 cycles 1, 2
• Unscheduled bleeding typically decreases from approximately 30% in cycle 1 to 15-20% by cycle 4 6
• If unacceptable bleeding persists beyond 3 months, consider alternative contraceptive methods 1
• For persistent irregular bleeding, NSAIDs for 5-7 days or short-term treatment with higher-dose estrogen (10-20 days) may be considered 1