Pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity (1,2)
Various routes of administration and doses can be used which differs from intermittent luteal phase oral administration, through intramuscular injection to continuous local administration by an IUD (1).
- oral progestogens
- administered during the luteal phase of the cycle
- studies which have measured menstrual loss on women who have taken norethisterone 5 mg twice daily for 7 days during the luteal phase have reported either a slight decrease or even an increase in flow
- but taking norethisterone 5 mg three times a day from day 5-26 has been shown to be effective
- oral progesterones at very large dosages (30mg/day) has been used to control heavy bleeding
- usually effective within 24 - 48 hours
- the dose can be reduced and then finally stopped over the next few days
- there is concern (increased risk of venous thromboembolism) regarding the use of progestogens in doses greater than those needed
- oral progestogens given only during the luteal phase is not recommended by NICE for the treatment of heavy menstrual bleeding (2)
- depot or implant progestogens
- depot-medroxyprogesterone acetate (DMPA) at a dose of 150 mg administered every 3 months will cause 45-50% of women to become amenorrheic after 1 year of use (although there can be irregular spotting or bleeding and rarely heavy bleeding in the first few months)
- due to the increased risk of osteoporosis, discontinuation of DMPA is recommended at the age of 40 years
- should not be used until a definite diagnosis has been established and the possibility of genital tract malignancy has been ruled out
- Intrauterine progestogens
- NICE considers levonorgestrel intra-uterine system (LNG-IUS) as the first line treatment method
- may cause changes in the bleeding patterns in the first few cycles (sometimes may persist for longer than 6 months) (2)
- additional advantages include - contraception and treatment reversibility (1)
Reference:
- 1. Peter Joseph O'Donovan, Charles E Miller. Modern Management of Abnormal Uterine Bleeding (2008)
- 2. National Institute for Health and Clinical Excellence (NICE) 2016. Heavy menstrual bleeding