Cochrane for Clinicians

Putting Evidence into Practice

Heavy Menstrual Bleeding in Premenopausal Patients and the Role of NSAIDs


Am Fam Physician. 2020 Aug 1;102(3):147-148.

Author disclosure: No relevant financial affiliations.

Clinical Question

Do nonsteroidal anti-inflammatory drugs (NSAIDs) effectively reduce heavy menstrual bleeding in premenopausal patients?

Evidence-Based Answer

NSAIDs are effective for reducing heavy menstrual bleeding in premenopausal patients with menorrhagia when compared with placebo. However, NSAIDs are less effective than tranexamic acid (Cyklokapron) and the levonorgestrel-releasing intrauterine system (Mirena) for reducing heavy menstrual bleeding. Adverse effects of NSAIDs, particularly gastrointestinal effects, are variable in frequency, although typically not severe.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Menorrhagia, or heavy menstrual bleeding, is defined as 80 mL or more of menstrual blood loss per period, although in practice the diagnosis is based on patient report of an amount or frequency of blood loss that interferes with physical or psychosocial well-being. This common gynecologic problem affects 30% of patients of reproductive age. It is an important cause of health care resource utilization and a common condition seen in the primary care setting.2,3 The authors of this Cochrane review sought to determine the safety and effectiveness of NSAID therapy for heavy menstrual bleeding in comparison with placebo and other common treatments.

This Cochrane review included 19 randomized controlled trials involving 759 premenopausal patients with heavy menstrual bleeding without a pathologic or iatrogenic cause.1 One trial took place in Canada, 13 in Europe, two in Australia, and three in Asia, and they involved patients 12 to 55 years of age. The primary outcomes included subjective and objective menstrual blood loss. Because of differing study designs, the meta-analysis included nine trials with 419 patients; the other 10 trials were described individually.

Compared with placebo, mefenamic acid (Ponstel; 500 mg three times daily) taken from start to finish of menses resulted in fewer reports of heavy

Author disclosure: No relevant financial affiliations.


show all references

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

2. Fraser IS, Mansour D, Breymann C, et al. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynaecol Obstet. 2015;128(3):196–200.

3. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. NICE guideline [NG88]. Last updated March 31, 2020. Accessed June 30, 2020.

4. Kadir RA, Lukes AS, Kouides PA, et al. Management of excessive menstrual bleeding in women with hemostatic disorders. Fertil Steril. 2005;84(5):1352–1359.

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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