Table 8.2Pharmaceutical options for treating HMB; discuss the risks and benefits of each option with the woman and provide information and support to aid decision making

Pharmaceutical treatmentHow it worksWhat is it?Effect on menstrual bleedingIs it a contraceptive?Will it impact on future fertility?Possible unwanted outcomes
Levonorgestrel-releasing intrauterine system (LNG-IUS)Prevents proliferation of the endometriumA small plastic device, placed in the uterus, which slowly releases progestogenBleeding reduced by up to 95%; full benefit may not be seen for 6 monthsYesNoCommon: irregular bleeding that may last for over 6 months; hormone-related problems such as breast tenderness, acne or headaches, which, if present, are generally minor and transient

Less common amenorrhoea

Rare: uterine perforation at the time of IUS insertion
Tranexamic acidIt is an antifibrinolyticTwo tablets orally, 3 to 4 times a day, from day 1 of the cycle for up to 4 daysBleeding reduced by up to 58%NoNoLess common: indigestion; diarrhoea; headaches
Nonsteroidal anti-inflammatory drugs (NSAIDs)Reduces production of prostaglandinTablets orally from day 1, or just before, until heavy blood loss has stoppedBleeding reduced by up to 49%NoNoCommon: indigestion; diarrhoea

Rare: worsening of asthma in sensitive individuals; peptic ulcers with possible bleeding and peritonitis
Combined oral contraceptives (COCsPrevents proliferation of the endometriumOne pill daily for 21 days, followed by a 7 day breakBleeding reduced by 43%YesNoCommon: mood changes; headaches; nausea; fluid retention; breast tenderness

Rare: deep vein thrombosis; stroke; heart attacks
Oral progestogen (norethisterone)Prevents proliferation of the endometriumTablets, orally, 15 mg from day 5 to day 26 of cycleBleeding reduced by up to 83% in the long termYesNoCommon: weight gain; bloating; breast tenderness; headaches; acne (but all are usually minor and transient)

Rare: depression
Injected or implanted progestogenPrevents proliferation of the endometriumInjected intramuscularly every 12 weeks; a subdermal implant is also available that is licensed for 3 yearsBleeding is likely to stop completelyYesNoCommon: weight gain; irregular bleeding; amenorrhoea; premenstrual-like syndrome (including bloating, fluid retention, breast tenderness)

Less common: small loss of bone mineral density, largely recovered when treatment is discontinued
Gonadotrophin-releasing hormone analogue (GnRH-a)Stops production of estrogen and progesteroneMonthly injection (for 3–6 months); if used for more than 6 months, ‘add-back’ therapy is recommendedBleeding stopped completely in 89% of womenNoNoCommon: menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness)

Less common: osteoporosis, particularly trabecular bone with longer than 6 months' use

From: 8, Pharmaceutical treatments for HMB

Cover of Heavy Menstrual Bleeding
Heavy Menstrual Bleeding.
NICE Clinical Guidelines, No. 44.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2007 Jan.
Copyright © 2007, National Collaborating Centre for Women's and Children's Health.

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