title: Nonsurgical management of heavy menstrual bleeding: a systematic review.
abstract: OBJECTIVE
  To compare the effectiveness of nonsurgical abnormal uterine bleeding treatments for bleeding control, quality of life (QOL), pain, sexual health, patient satisfaction, additional treatments needed, and adverse events.
  
  
  METHODS
  MEDLINE, Cochrane databases, and Clinicaltrials.gov were searched from inception to May 2012. We included randomized controlled trials of nonsurgical treatments for abnormal uterine bleeding presumed secondary to endometrial dysfunction and abnormal uterine bleeding presumed secondary to ovulatory dysfunction. Interventions included the levonorgestrel intrauterine system, combined oral contraceptive pills (OCPs), progestins, nonsteroidal anti-inflammatory drugs (NSAIDs), and antifibrinolytics. Gonadotropin-releasing hormone agonists, danazol, and placebo were allowed as comparators.
  
  
  METHODS
  Two reviewers independently screened 5,848 citations and extracted eligible trials. Studies were assessed for quality and strength of evidence.
  
  
  RESULTS
  Twenty-six articles met inclusion criteria. For reduction of menstrual bleeding in women with abnormal uterine bleeding presumed secondary to endometrial dysfunction, the levonorgestrel intrauterine system (71-95% reduction), combined OCPs (35-69% reduction), extended cycle oral progestins (87% reduction), tranexamic acid (26-54% reduction), and NSAIDs (10-52% reduction) were all effective treatments. The levonorgestrel intrauterine system, combined OCPs, and antifibrinolytics were all superior to luteal-phase progestins (20% increase in bleeding to 67% reduction). The levonorgestrel intrauterine system was superior to combined OCPs and NSAIDs. Antifibrinolytics were superior to NSAIDs for menstrual bleeding reduction. Data were limited on other important outcomes such as QOL for women with abnormal uterine bleeding presumed secondary to endometrial dysfunction and for all outcomes for women with abnormal uterine bleeding presumed secondary to ovulatory dysfunction.
  
  
  CONCLUSIONS
  For the reduction in mean blood loss in women with heavy menstrual bleeding presumed secondary to abnormal uterine bleeding presumed secondary to endometrial dysfunction, we recommend the use of the levonorgestrel intrauterine system over OCPs, luteal-phase progestins, and NSAIDs. For other outcomes (QOL, pain, sexual health, patient satisfaction, additional treatments needed, and adverse events) and for treatment of abnormal uterine bleeding presumed secondary to ovulatory dysfunction, we were unable to make recommendations based on the limited available data.
authors: Women and Infants Hospital, Alpert Medical School of Brown University, Providence, Rhode Island; the University of Texas Southwestern Medical Center, Dallas, Texas; University Medical Group, Greenville Hospital Systems, Greenville, South Carolina; the University of Texas Health Science Center, San Antonio, Texas; Duke University Medical Center, Durham, North Carolina; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; the University of New Mexico Health Sciences Center, Albuquerque, New Mexico; and Tufts Medical Center, Boston, Massachusetts.
authors: Kristen A
authors: KA
authors: Matteson
authors: David D
authors: DD
authors: Rahn
authors: Thomas L
authors: TL
authors: Wheeler
authors: Elizabeth
authors: E
authors: Casiano
authors: Nazema Y
authors: NY
authors: Siddiqui
authors: Heidi S
authors: HS
authors: Harvie
authors: Mamta M
authors: MM
authors: Mamik
authors: Ethan M
authors: EM
authors: Balk
authors: Vivian W
authors: VW
authors: Sung
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D003277:Contraceptives, Oral, Combined / Q000627:therapeutic use*; D004412:Dysmenorrhea / Q000188:drug therapy; D005260:Female; D006801:Humans; D007436:Intrauterine Devices, Medicated; D008595:Menorrhagia / Q000188:drug therapy*; D017060:Patient Satisfaction; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D060728:Reproductive Health; D014148:Tranexamic Acid / Q000627:therapeutic use
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D000933:Antifibrinolytic Agents; D003277:Contraceptives, Oral, Combined; D014148:Tranexamic Acid
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