Cochrane for Clinicians

Putting Evidence into Practice

Combined Oral Contraceptives for Heavy Menstrual Bleeding


Am Fam Physician. 2019 Dec 1;100(11):677-678.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are combined oral contraceptives effective in decreasing menorrhagia?

Evidence-Based Answer

Combined oral contraceptives decrease the number of women reporting menorrhagia over six months compared with placebo (absolute risk reduction [ARR] = 36.7%; number needed to treat [NNT] = 2.7). The levonorgestrel-releasing intrauterine system (Mirena) reduces the number of women with heavy menstrual bleeding (based on a score of less than 100 on the Pictorial Blood Loss Assessment Chart) when compared with combined oral contraceptives.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Menorrhagia is excessive blood loss that affects women's quality of life and can lead to anemia. The overall prevalence of menorrhagia in women of reproductive age is 30%, and these patients represent 30% of gynecologic referrals in the United States.1,2 Medical treatments include oral contraceptives,3,4 nonsteroidal anti-inflammatory drugs (NSAIDs),5 and antifibrinolytics.6 The authors of this Cochrane review aimed to determine the effectiveness of combined oral contraceptives for menorrhagia in women.

This Cochrane review included eight randomized controlled trials and 805 reproductive-aged women.1 The follow-up time ranged from one to 12 months. The trials compared the effectiveness of combined oral contraceptives with placebo or other medical treatments with regard to menstrual bleeding as determined by patient report, women's satisfaction based on a validated questionnaire, adverse effects, and hemoglobin levels.

In two trials with 421 patients, combined oral contraceptives reduced menorrhagia compared with placebo (ARR = 36.7%; 95% CI, 28% to 44%; NNT = 2.7; 95% CI, 2.2 to 3.6). Patients who took combined oral contraceptives also reported improved quality of life as measured using the Work Productivity and Activity Impairment Questionnaire: General Health version 2.0 (366 patients; data could not be pooled but

Author disclosure: No relevant financial affiliations.


show all references

1. Lethaby A, Wise MR, Weterings MA, et al. Combined hormonal contraceptives for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;(2):CD000154....

2. El-Hemaidi I, Gharaibeh A, Shehata H. Menorrhagia and bleeding disorders. Curr Opin Obstet Gynecol. 2007;19(6):513–520.

3. American College of Obstetricians and Gynecologists, Committee on Practice Bulletins—Gynecology. Practice bulletin no. 136. Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013;122(1):176–185.

4. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. NICE guideline NG88. Updated November 2018. Accessed March 26, 2019.

5. Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;(9):CD000400.

6. Bryant-Smith AC, Lethaby A, Farquhar C, et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018;(4):CD000249.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at



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