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Nonsurgical Management of Heavy Menstrual Bleeding: A Systematic Review

Matteson, Kristen A. MD, MPH; Rahn, David D. MD; Wheeler, Thomas L. II MD, MSPH; Casiano, Elizabeth MD; Siddiqui, Nazema Y. MD, MHSc; Harvie, Heidi S. MD, MBA, MSCE; Mamik, Mamta M. MD; Balk, Ethan M. MD, MPH; Sung, Vivian W. MD, MPH; for the Society of Gynecologic Surgeons Systematic Review Group

doi: 10.1097/AOG.0b013e3182839e0e
Review

OBJECTIVE: To compare the effectiveness of nonsurgical abnormal uterine bleeding treatments for bleeding control, quality of life (QOL), pain, sexual health, patient satisfaction, additional treatments needed, and adverse events.

DATA SOURCES: MEDLINE, Cochrane databases, and Clinicaltrials.gov were searched from inception to May 2012. We included randomized controlled trials of nonsurgical treatments for abnormal uterine bleeding presumed secondary to endometrial dysfunction and abnormal uterine bleeding presumed secondary to ovulatory dysfunction. Interventions included the levonorgestrel intrauterine system, combined oral contraceptive pills (OCPs), progestins, nonsteroidal anti-inflammatory drugs (NSAIDs), and antifibrinolytics. Gonadotropin-releasing hormone agonists, danazol, and placebo were allowed as comparators.

METHODS OF STUDY SELECTION: Two reviewers independently screened 5,848 citations and extracted eligible trials. Studies were assessed for quality and strength of evidence.

TABULATION, INTEGRATION, AND RESULTS: Twenty-six articles met inclusion criteria. For reduction of menstrual bleeding in women with abnormal uterine bleeding presumed secondary to endometrial dysfunction, the levonorgestrel intrauterine system (71–95% reduction), combined OCPs (35–69% reduction), extended cycle oral progestins (87% reduction), tranexamic acid (26–54% reduction), and NSAIDs (10–52% reduction) were all effective treatments. The levonorgestrel intrauterine system, combined OCPs, and antifibrinolytics were all superior to luteal-phase progestins (20% increase in bleeding to 67% reduction). The levonorgestrel intrauterine system was superior to combined OCPs and NSAIDs. Antifibrinolytics were superior to NSAIDs for menstrual bleeding reduction. Data were limited on other important outcomes such as QOL for women with abnormal uterine bleeding presumed secondary to endometrial dysfunction and for all outcomes for women with abnormal uterine bleeding presumed secondary to ovulatory dysfunction.

CONCLUSION: For the reduction in mean blood loss in women with heavy menstrual bleeding presumed secondary to abnormal uterine bleeding presumed secondary to endometrial dysfunction, we recommend the use of the levonorgestrel intrauterine system over OCPs, luteal-phase progestins, and NSAIDs. For other outcomes (QOL, pain, sexual health, patient satisfaction, additional treatments needed, and adverse events) and for treatment of abnormal uterine bleeding presumed secondary to ovulatory dysfunction, we were unable to make recommendations based on the limited available data.

Many nonsurgical treatments effectively reduce menstrual bleeding resulting from endometrial hemostatic dysfunction.

Women and Infants Hospital, Alpert Medical School of Brown University, Providence, Rhode Island; the University of Texas Southwestern Medical Center, Dallas, Texas; University Medical Group, Greenville Hospital Systems, Greenville, South Carolina; the University of Texas Health Science Center, San Antonio, Texas; Duke University Medical Center, Durham, North Carolina; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; the University of New Mexico Health Sciences Center, Albuquerque, New Mexico; and Tufts Medical Center, Boston, Massachusetts.

Corresponding author: Kristen A. Matteson MD, MPH, Women & Infants Hospital, 101 Dudley Street, Providence, RI 02905; e-mail: KMatteson@wihri.org.

Supported by the Society of Gynecologic Surgeons, who provided administrative and financial support for the Systematic Review Group's meetings and consultants, including Dr. Balk (www.sgsonline.org). Dr. Matteson is supported by K23HD057957, and Dr. Sung is supported by K23HD060665

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2013 The American College of Obstetricians and Gynecologists