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Medical Management of Heavy Menstrual Bleeding: A Comprehensive Review of the Literature

Bitzer, Johannes MD, PhD*; Heikinheimo, Oskari MD, PhD; Nelson, Anita L. MD; Calaf-Alsina, Joaquin MD, PhD§; Fraser, Ian S. MD, DSc

Obstetrical & Gynecological Survey: February 2015 - Volume 70 - Issue 2 - p 115–130
doi: 10.1097/OGX.0000000000000155
CME Articles

Importance Heavy menstrual bleeding (HMB) is a common complaint among reproductive-aged women, which negatively affects their health as well as their social, professional, and family lives. Modern medical management usually provides effective control of HMB irrespective of the underlying cause. Surgical interventions should be reserved for women with significant pelvic pathology and those unresponsive to medical therapy.

Objective The aim of this review was to provide a comprehensive summary of the efficacy and safety of available medical treatments of HMB.

Evidence Acquisition A comprehensive MEDLINE and EMBASE literature search was undertaken using selected terms associated with HMB to identify clinical studies published before March 20, 2013, that reported changes in menstrual blood loss in women receiving medical intervention.

Results The effectiveness of treatments to reduce HMB due to endometrial dysfunction in descending order was as follows: (1) the levonorgestrel-releasing intrauterine system (LNG-IUS) (initial release rate of 20 μg of LNG per 24 hours), (2) combined hormonal contraceptives (oral or transvaginal), (3) tranexamic acid, and (4) long-course oral progestogens (≥3 weeks per cycle). The LNG-IUS was found to reduce HMB due to some structural causes (leiomyomas and adenomyosis). The reduction in menstrual blood loss achieved with nonsteroidal anti-inflammatory drugs and short-course oral progestogens (≤14 days per cycle) is less impressive but may be sufficient for women who have marginally increased blood loss.

Conclusions and Relevance For women not seeking pregnancy, the LNG-IUS is the first-line medical therapy for HMB, with combined hormonal contraceptives as second choice. For other women, fewer effective options exist.

Target Audience Obstetricians and gynecologists, family physicians.

Learning Objectives After completing this CME activity, physicians should be better able to describe the most effective medical therapies available for women who present with HMB, to prescribe appropriate therapies based on the women’s fertility needs/requirements, and to identify therapies that may be perceived as effective but in which robust data are lacking.

*Professor, Chairman of Department, Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland; †Professor, University of Helsinki, Department of Obstetrics and Gynaecology, and Helsinki University Central Hospital, Kätilöopisto Hospital, Helsinki, Finland; ‡Professor, Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA; §Professor, Head of Department, Department of Obstetrics and Gynaecology, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma, Barcelona, Spain; and ¶Professor in Reproductive Medicine, Department of Obstetrics and Gynaecology, Elizabeth II Research Institute for Mothers & Infants, University of Sydney, Sydney, New South Wales, Australia

Dr Bitzer serves on advisory boards of Bayer HealthCare, MSD/Merck, Gedeon Richter, Vifor, and Lilly. Dr Heikinheimo serves occasionally on advisory boards for Bayer HealthCare, Gedeon Richter, and MSD/Merck and has designed educational events with these companies. Dr Nelson has received honoraria for promotional talks and for participating in scientific advisory boards for Bayer HealthCare, Actavis, ContraMed, Medicus, Merck, Pfizer, and Teva. Dr Calaf-Alsina has received support to attend clinical meetings and participate in scientific advisory boards for Bayer HealthCare, Ely Lilly, Merck Sharp & Dohme, Pfizer, and Janssen. Dr Fraser has undertaken lectures, advisory boards, and consultancies and received research support from Bayer HealthCare, MSD/Merck, Vifor Pharma, and Daiichi-Sankyo.

All of the authors’ spouses/life partners (if any) and LCMEI staff and their spouses/life partners (if any) in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.

Lippincott CME Institute has identified and resolved all conflicts of interest concerning this educational activity.

The authors have disclosed that certain drugs discuss in this article has not been approved by the U.S. Food and Drug Administration. Please consult the product’s labeling for approved information.

Correspondence requests to: Ian S. Fraser, MD, DSc, Department of Obstetrics and Gynaecology, D02 Queen Elizabeth II Research Institute for Mothers and Infants, The Queen Elizabeth II and Victor Coppleson Building, Blackburn Avenue, University of Sydney, Sydney, New South Wales 2006, Australia. E-mail:

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