Medications are an important tool in the management of menstrual disorders. One of the many positive aspects of medications is that, when appropriate, they carry comparatively little risk and they are reversible—meaning that if they don’t work or if you suffer bothersome side effects, you can simply stop them.
For the purposes of this discussion, we will focus on two separate categories of medications – hormonal and non-hormonal. In addition, we’ll discuss the Mirena intrauterine device (IUD). The Mirena IUD releases a small amount of a hormone — levonorgestrel — into the uterine cavity each day and is a very good “first line” approach to the management for abnormal menstrual bleeding.
Finally, there are non-hormonal medications available that can be quite useful under special circumstances. This includes Lysteda (transexamic acid) and Lupron (leuprolide acetate).
Managing Heavy Bleeding / Menstruation With Hormones
Birth control pills, patches and rings
Birth control pills are often used in women who suffer with irregular menses or periods that are heavy and associated with clotting and cramping. Before birth control pills are administered, a brief evaluation is generally required. For women over the age of 35, the evaluation is a bit more involved and may entail a biopsy of the uterine lining (endometrial biopsy) or a hysteroscopy (passing a small lit-telescope into the uterine cavity).
Birth control pills are excellent in women who are non-smokers and do not have significant risk factors for heart disease and strokes. Women with hypertension, abnormally high cholesterol levels or who have a strong family history of heart disease and strokes are often asked to avoid birth control pills, patches and rings. Also, women who have a history of a deep vein thrombosis or a pulmonary embolus cannot used any of these combination estrogen/progestin hormones.
Progestins are in a family of medications that mimic the hormone progesterone and can be very useful in regulating menses in women with irregular cycles. They may also be useful in women who have heavy or painful periods. Although progestins are hormones, they do not carry the same risks often associated with estrogens. For instance, they can be used in women with a history of hypertension or who have a smoking history. Although progestins are often helpful in regulation menses that occur without “rhyme or reason” they are often associated with side effects such as bloatedness. The more commonly used progestins include norethindrone acetate, medroxyprogesterone (Provera) and megesterol acetate (Megace).
Progestin-containing Intrauterine Device (IUD) – Mirena
The Mirena IUD supplies a small but steady quantity of progestins on a daily basis. The IUD can be inserted with ultrasound guidance thereby minimizing most of the risks of the insertion procedure—such as uterine perforation. Some women are concerned about pain during the IUD insertion but this can be prevented with the use of intravenous sedation. Similar to other “pills, patches and rings” the Mirena IUD is reversible. If it produces the desired results no other form of therapy is needed. The Mirena can be changed in 5 years if another one is required. If, however, the Mirena IUD does not produce the desired result, then one can choose another option—often surgical.
The Mirena tends to work best in a uterus that does not contain significant fibroids or polyps. Any fibroids within the uterine cavity (submucous leiomyomas) should be removed prior to inserting the Mirena IUD. Additionally, Mirena to works best in the “average size” uterus—something you’ll have to discuss with your health care provider.
Non-hormonal management of abnormal menstruation—Lysteda (Tranexamic acid)
Lysteda (Tranexemacid acid) was approved by the FDA for the treatment of heavy menstrual bleeding in 2009—prior to which it was widely used in Canada and Europe. Lysteda is not a hormone and falls under a separate category of medications known as antifibrinolytics. These medications work on the clotting mechanism—the discussion of which is beyond the scope of this brief article.
The advantages of Lysteda are that it can be used while trying to conceive and is taken only during menses, rather than daily. It is generally avoided in women that have an increased risk of thromboembolism (clot formation). Lysteda is very effective in managing the most troublesome cases of heavy menstrual bleeding that do not respond to hormones or IUDs. We often use it for women who are developing severe anemia—even if just to stabilize them prior to surgery. Many studies have shown that Lysteda reduces menstrual blood loss by 26 – 54% The most commonly reported troublesome side effects include menstrual cramps, headaches, back pain and nausea.