What is the best birth control to alleviate menorrhagia (heavy menstruation)?

Best Birth Control for Heavy Menstruation

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective contraceptive option for reducing heavy menstrual bleeding, achieving 71-95% reduction in menstrual blood loss and representing the optimal first-line treatment for women seeking both contraception and management of menorrhagia. 1

Why LNG-IUD is Superior

The LNG-IUD outperforms all other contraceptive options for heavy bleeding:

• Dramatically reduces menstrual blood loss by 66.91 mL per cycle compared to oral medications, with many women eventually experiencing only light bleeding or complete amenorrhea 2
• Most effective long-term option according to the American Heart Association, with sustained bleeding reduction over 5-7 years of use 1, 3
• Superior to oral contraceptives in head-to-head trials, with greater bleeding reduction, improved quality of life, and higher continuation rates at 2 years 2
• Comparable satisfaction to surgical options like endometrial ablation, but more cost-effective within a 2-year timeframe 2

Specific LNG-IUD Products Available

Three levonorgestrel IUDs are FDA-approved and equally effective for heavy bleeding 4:

• Mirena (52 mg levonorgestrel): Approved for 5 years, effective up to 7 years 4
• Liletta (52 mg levonorgestrel): Approved for 3 years 4
• Skyla (13.5 mg levonorgestrel): Approved for 3 years, lower dose may be less effective for heavy bleeding 4

Expected Bleeding Pattern Changes

Understanding what to expect improves adherence 4:

• Initial irregular bleeding is common in first 3-6 months but typically resolves 4
• Progressive reduction in overall bleeding volume over time 4
• Many women develop amenorrhea (no periods), which is safe and often desired 4, 3
• Significant improvement in dysmenorrhea (painful periods) for most users 4

Alternative Options If LNG-IUD Not Suitable

If the LNG-IUD cannot be used or is declined, consider these alternatives in order of effectiveness:

Combined Hormonal Contraceptives (CHCs)

• Moderately effective for reducing heavy bleeding when used continuously or in extended cycles 4, 5
• Can be used for 10-20 days to acutely manage heavy bleeding episodes 4, 5
• Less effective than LNG-IUD but more acceptable to some women who prefer oral medication 2

Progestin-Only Pills

• Less effective than LNG-IUD or CHCs but may reduce bleeding in some women 4
• Require daily adherence, which affects efficacy 4

Copper IUD - Avoid

• Contraindicated for heavy bleeding as it typically increases menstrual blood loss and cramping 4
• Should not be used when treating menorrhagia 4

Managing Breakthrough Bleeding

If irregular bleeding persists with any method 4, 1:

• First-line: NSAIDs for 5-7 days during bleeding episodes (mefenamic acid, ibuprofen, naproxen) 4, 1
• Second-line: Short course of estrogen or CHCs for 10-20 days if NSAIDs fail 4
• Avoid aspirin as it may increase bleeding 1

Critical Exclusions Before Placement

Evaluate for these conditions that require alternative management 5:

• Rule out pregnancy, STIs, uterine fibroids, polyps, adenomyosis before attributing bleeding to functional causes 5
• Advanced HIV/AIDS (CD4 <200) is a relative contraindication to IUD insertion until immune status improves 4
• Active pelvic infection requires treatment before IUD placement, though asymptomatic high-risk women can be screened at insertion 4

Important Caveats

• Nulliparous women are excellent candidates for LNG-IUD despite older concerns; it does not cause infertility 4
• Small infection risk exists only in first 21 days after insertion 4
• Women with severe thrombocytopenia may particularly benefit from LNG-IUD as it treats both heavy bleeding and reduces bleeding risk 4
• Cost-effectiveness favors LNG-IUD over both surgical ablation and hysterectomy for up to 10 years 2