What is the most effective oral contraceptive pill (OCP) formulation for reducing menorrhagia (heavy menstrual bleeding) and dysmenorrhea (heavy cramping)?

From the Guidelines

For reducing heavy menstrual bleeding and heavy cramping, low-dose combined oral contraceptive pills (COCs) are a recommended treatment option, as stated in the 2013 U.S. Selected Practice Recommendations for Contraceptive Use 1. When considering the best oral contraceptive pill formulation, it's essential to evaluate the patient's individual needs and medical eligibility.

• The patient's medical history, including any underlying gynecological problems, should be assessed to determine the best course of treatment.
• If an underlying gynecologic problem is identified, treating the condition or referring for care is crucial before initiating hormonal treatment.
• Low-dose COCs can be considered for short-term treatment (10-20 days) to reduce heavy or prolonged bleeding, as suggested by the 2013 U.S. Selected Practice Recommendations for Contraceptive Use 1.
• Additionally, non-hormonal options like NSAIDs can be used for short-term treatment (5-7 days) to alleviate symptoms.
• It's also important to counsel the patient on alternative contraceptive methods if heavy or prolonged bleeding persists and is unacceptable to the patient. Some key points to consider when prescribing low-dose COCs include:
• Starting with a standard 21/7 regimen and transitioning to extended use if needed to reduce or eliminate periods altogether.
• Monitoring the patient for side effects, such as nausea, breast tenderness, and spotting, particularly in the first few months.
• Adjusting the formulation or considering non-hormonal options like NSAIDs or tranexamic acid as adjuncts if bleeding remains problematic after 3 months.

From the Research

Oral Contraceptive Pill Formulations for Reducing Heavy Menstrual Bleeding and Cramping

• The combined oral contraceptive pill (COCP) has been shown to reduce heavy menstrual bleeding (HMB) and improve menstrual cramping 2.
• A study found that COCP with a step-down oestrogen and step-up progestogen regimen improved response to treatment and lowered menstrual blood loss (MBL) compared to placebo 2.
• The levonorgestrel-releasing intrauterine system (LNG IUS) was found to be more effective than COCP in reducing MBL, but it was not clear whether satisfaction with treatment or adverse effects varied according to which treatment was used 2.
• Drospirenone-containing oral contraceptives have been shown to alleviate premenstrual symptoms, including bloating, breast tenderness, and mood changes 3, 4, 5.
• A study comparing drospirenone 3 mg plus ethinyl estradiol 30 μg with levonorgestrel 150 µg plus ethinyl estradiol 30 µg found that both treatments had similar effects on premenstrual symptoms, but drospirenone was associated with improved physical well-being and a decrease in acne 4.
• Drospirenone-containing oral contraceptives have been found to be safe and effective in reducing soluble adhesion molecules, which are associated with endothelial function 6.

Comparison of Different Oral Contraceptive Formulations

• A study comparing COCP with a contraceptive vaginal ring (CVR) found that both treatments had similar effects on menstrual bleeding and cramping, but COCP was associated with more nausea 2.
• A study comparing drospirenone 3 mg plus ethinyl estradiol 20 μg with levonorgestrel 150 µg plus ethinyl estradiol 30 µg found that both treatments had similar effects on premenstrual symptoms, but drospirenone was associated with improved physical well-being and a decrease in acne 4.
• A study evaluating the effect of three contraceptive pills containing ethinylestradiol (20 or 30 mcg) in combination with drospirenone (DRSP) and levonorgestrel (LNG) on plasma concentration of adhesion molecules found that all three treatments reduced soluble adhesion molecules, but DRSP/20 EE and LNG/30 EE induced favorable changes in endothelial function 6.

Adverse Effects and Safety

• COCP has been associated with minor adverse events, including breast pain and nausea 2.
• Drospirenone-containing oral contraceptives have been found to be safe and effective, with no evidence of clinically adverse effects on carbohydrate metabolism, lipids, blood pressure, weight, serum potassium, or increased thrombotic events compared to other low-dose oral contraceptives 5.
• A study found that drospirenone-containing oral contraceptives were associated with a decrease in acne and hirsutism, and an improvement in fluid retention symptoms 5.