Comparison between antifibrinolytic and antiprostaglandin treatment in the reduction of increased menstrual blood loss in women with intrauterine contraceptive devices

Interventions to prevent or treat heavy menstrual bleeding or pain associated with intrauterine-device use

BACKGROUND

Heavy menstrual bleeding and pain are common reasons women discontinue intrauterine device (IUD) use. Copper IUD (Cu IUD) users tend to experience increased menstrual bleeding, whereas levonorgestrel IUD (LNG IUD) users tend to have irregular menstruation. Medical therapies used to reduce heavy menstrual bleeding or pain associated with Cu and LNG IUD use include non-steroidal anti-inflammatory drugs (NSAIDs), anti-fibrinolytics and paracetamol. We analysed treatment and prevention interventions separately because the expected outcomes for treatment and prevention interventions differ. We did not combine different drug classes in the analysis as they have different mechanisms of action. This is an update of a review originally on NSAIDs. The review scope has been widened to include all interventions for treatment or prevention of heavy menstrual bleeding or pain associated with IUD use.

OBJECTIVES

To evaluate all randomized controlled trials (RCTs) that have assessed strategies for treatment and prevention of heavy menstrual bleeding or pain associated with IUD use, for example, pharmacotherapy and alternative therapies.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2021.

SELECTION CRITERIA

We included RCTs in any language that tested strategies for treatment or prevention of heavy menstrual bleeding or pain associated with IUD (Cu IUD, LNG IUD or other IUD) use. The comparison could be no intervention, placebo or another active intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, and extracted data. Primary outcomes were volume of menstrual blood loss, duration of menstruation and painful menstruation. We used a random-effects model in all meta-analyses. Review authors assessed the certainty of evidence using GRADE.

MAIN RESULTS

This review includes 21 trials involving 3689 participants from middle- and high-income countries. Women were 18 to 45 years old and either already using an IUD or had just had one placed for contraception. The included trials examined NSAIDs and other interventions. Eleven were treatment trials, of these seven were on users of the Cu IUD, one on LNG IUD and three on an unknown type. Ten were prevention trials, six focused on Cu IUD users, and four on LNG IUD users. Sixteen trials had high risk of detection bias due to subjective assessment of pain and bleeding. Treatment of heavy menstrual bleeding Cu IUD Vitamin B1 resulted in fewer pads used per day (mean difference (MD) -7.00, 95% confidence interval (CI) -8.50 to -5.50) and fewer bleeding days (MD -2.00, 95% CI -2.38 to -1.62; 1 trial; 110 women; low-certainty evidence) compared to placebo. The evidence is very uncertain about the effect of naproxen on the volume of menstruation compared to placebo (odds ratio (OR) 0.09, 95% CI 0.00 to 1.78; 1 trial, 40 women; very low-certainty evidence). Treatment with mefenamic acid resulted in less volume of blood loss compared to tranexamic acid (MD -64.26, 95% CI -105.65 to -22.87; 1 trial, 94 women; low-certainty evidence). However, there was no difference in duration of bleeding with treatment of mefenamic acid or tranexamic acid (MD 0.08 days, 95% CI -0.27 to 0.42, 2 trials, 152 women; low-certainty evidence). LNG IUD The use of ulipristal acetate in LNG IUD may not reduce the number of bleeding days in 90 days in comparison to placebo (MD -9.30 days, 95% CI -26.76 to 8.16; 1 trial, 24 women; low-certainty evidence). Unknown IUD type Mefenamic acid may not reduce volume of bleeding compared to Vitex agnus measured by pictorial blood assessment chart (MD -2.40, 95% CI -13.77 to 8.97; 1 trial; 84 women; low-certainty evidence). Treatment of pain Cu IUD Treatment with tranexamic acid and sodium diclofenac may result in little or no difference in the occurrence of pain (OR 1.00, 95% CI 0.06 to 17.25; 1 trial, 38 women; very low-certainty evidence). Unknown IUD type Naproxen may reduce pain (MD 4.10, 95% CI 0.91 to 7.29; 1 trial, 33 women; low-certainty evidence). Prevention of heavy menstrual bleeding Cu IUD We found very low-certainty evidence that tolfenamic acid may prevent heavy bleeding compared to placebo (OR 0.54, 95% CI 0.34 to 0.85; 1 trial, 310 women). There was no difference between ibuprofen and placebo in blood volume reduction (MD -14.11, 95% CI -36.04 to 7.82) and duration of bleeding (MD -0.2 days, 95% CI -1.40 to 1.0; 1 trial, 28 women, low-certainty evidence). Aspirin may not prevent heavy bleeding in comparison to paracetamol (MD -0.30, 95% CI -26.16 to 25.56; 1 trial, 20 women; very low-certainty evidence). LNG IUD Ulipristal acetate may increase the percentage of bleeding days compared to placebo (MD 9.50, 95% CI 1.48 to 17.52; 1 trial, 118 women; low-certainty evidence). There were insufficient data for analysis in a single trial comparing mifepristone and vitamin B. There were insufficient data for analysis in the single trial comparing tranexamic acid and mefenamic acid and in another trial comparing naproxen with estradiol. Prevention of pain Cu IUD There was low-certainty evidence that tolfenamic acid may not be effective to prevent painful menstruation compared to placebo (OR 0.71, 95% CI 0.44 to 1.14; 1 trial, 310 women). Ibuprofen may not reduce menstrual cramps compared to placebo (OR 1.00, 95% CI 0.11 to 8.95; 1 trial, 20 women, low-certainty evidence).

AUTHORS' CONCLUSIONS

Findings from this review should be interpreted with caution due to low- and very low-certainty evidence. Included trials were limited; the majority of the evidence was derived from single trials with few participants. Further research requires larger trials and improved trial reporting. The use of vitamin B1 and mefenamic acid to treat heavy menstruation and tolfenamic acid to prevent heavy menstruation associated with Cu IUD should be investigated. More trials are needed to generate evidence for the treatment and prevention of heavy and painful menstruation associated with LNG IUD.

Oral micronised flavonoids versus tranexamic acid for treatment of heavy menstrual bleeding secondary to copper IUD use: a randomised double-blind clinical trial

OBJECTIVE

The aim of the study was to compare the efficacy of micronised flavonoids versus tranexamic acid in reducing menstrual blood loss (MBL) associated with the use of the TCu 380A intrauterine contraceptive device (IUD) in women with heavy menstrual bleeding (HMB).

METHODS

We conducted a randomised double-blind clinical trial between October 2016 and August 2017 in 100 women with HMB (defined as a pictorial blood assessment chart [PBAC] score >100) secondary to IUD use. After assessment of MBL using PBAC score in a baseline cycle, participants were randomised to receive either oral tranexamic acid 500 mg or oral micronised flavonoids 500 mg every 6 h for the first three days of menstruation. PBAC scores were collected in the three subsequent treatment cycles. The primary outcome was the difference in PBAC scores between the groups. Two-way repeated measures ANOVA was used to assess the primary outcome of the change in PBAC scores.

RESULTS

Mean PBAC scores were significantly improved in the tranexamic acid group compared with the micronised flavonoids group (236 ± 48, 105 ± 26, 97 ± 16 and 93 ± 15 at the baseline, first, second and third study cycle, respectively, versus 227 ± 52, 139 ± 29, 128 ± 25 and 125 ± 24 in the micronised flavonoids group; p = .01). Moreover, the number of bleeding days and number of pads used were significantly reduced in the tranexamic acid group compared with the micronised flavonoids group (p = .009 and p = .03, respectively). Side effects were comparable between the two groups.

CONCLUSION

Oral tranexamic acid compared with oral micronised flavonoids is more effective in reducing HMB associated with copper IUD use. Treating IUD-induced HMB using tranexamic acid was more effective compared with micronised flavonoids in decreasing MBL volume and the number of bleeding days.

Antifibrinolytics for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important physical and social problem for women. Oral treatment for HMB includes antifibrinolytic drugs, which are designed to reduce bleeding by inhibiting clot-dissolving enzymes in the endometrium.Historically, there has been some concern that using the antifibrinolytic tranexamic acid (TXA) for HMB may increase the risk of venous thromboembolic disease. This is an umbrella term for deep venous thrombosis (blood clots in the blood vessels in the legs) and pulmonary emboli (blood clots in the blood vessels in the lungs).

OBJECTIVES

To determine the effectiveness and safety of antifibrinolytic medications as a treatment for heavy menstrual bleeding.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registers in November 2017, together with reference checking and contact with study authors and experts in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing antifibrinolytic agents versus placebo, no treatment or other medical treatment in women of reproductive age with HMB. Twelve studies utilised TXA and one utilised a prodrug of TXA (Kabi).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary review outcomes were menstrual blood loss (MBL), improvement in HMB, and thromboembolic events.

MAIN RESULTS

We included 13 RCTs (1312 participants analysed). The evidence was very low to moderate quality: the main limitations were risk of bias (associated with lack of blinding, and poor reporting of study methods), imprecision and inconsistency.Antifibrinolytics (TXA or Kabi) versus no treatment or placeboWhen compared with a placebo, antifibrinolytics were associated with reduced mean blood loss (MD -53.20 mL per cycle, 95% CI -62.70 to -43.70; I² = 8%; 4 RCTs, participants = 565; moderate-quality evidence) and higher rates of improvement (RR 3.34, 95% CI 1.84 to 6.09; 3 RCTS, participants = 271; moderate-quality evidence). This suggests that if 11% of women improve without treatment, 43% to 63% of women taking antifibrinolytics will do so. There was no clear evidence of a difference between the groups in adverse events (RR 1.05, 95% CI 0.93 to 1.18; 1 RCT, participants = 297; low-quality evidence). Only one thromboembolic event occurred in the two studies that reported this outcome.TXA versus progestogensThere was no clear evidence of a difference between the groups in mean blood loss measured using the Pictorial Blood Assessment Chart (PBAC) (MD -12.22 points per cycle, 95% CI -30.8 to 6.36; I² = 0%; 3 RCTs, participants = 312; very low quality evidence), but TXA was associated with a higher likelihood of improvement (RR 1.54, 95% CI 1.31 to 1.80; I² = 32%; 5 RCTs, participants = 422; low-quality evidence). This suggests that if 46% of women improve with progestogens, 61% to 83% of women will do so with TXA.Adverse events were less common in the TXA group (RR 0.66, 95% CI 0.46 to 0.94; I² = 28%; 4 RCTs, participants = 349; low-quality evidence). No thromboembolic events were reported in any group.TXA versus non-steroidal anti-inflammatory drugs (NSAIDs)TXA was associated with reduced mean blood loss (MD -73.00 mL per cycle, 95% CI -123.35 to -22.65; 1 RCT, participants = 49; low-quality evidence) and higher likelihood of improvement (RR 1.43, 95% CI 1.18 to 1.74; 1² = 0%; 2 RCTs, participants = 161; low-quality evidence). This suggests that if 61% of women improve with NSAIDs, 71% to 100% of women will do so with TXA. Adverse events were uncommon and no comparative data were available. No thromboembolic events were reported.TXA versus ethamsylateTXA was associated with reduced mean blood loss (MD 100 mL per cycle, 95% CI -141.82 to -58.18; 1 RCT, participants = 53; low-quality evidence), but there was insufficient evidence to determine whether the groups differed in rates of improvement (RR 1.56, 95% CI 0.95 to 2.55; 1 RCT, participants = 53; very low quality evidence) or withdrawal due to adverse events (RR 0.78, 95% CI 0.19 to 3.15; 1 RCT, participants = 53; very low quality evidence).TXA versus herbal medicines (Safoof Habis and Punica granatum)TXA was associated with a reduced mean PBAC score after three months' treatment (MD -23.90 pts per cycle, 95% CI -31.92 to -15.88; I² = 0%; 2 RCTs, participants = 121; low-quality evidence). No data were available for rates of improvement. TXA was associated with a reduced mean PBAC score three months after the end of the treatment phase (MD -10.40 points per cycle, 95% CI -19.20 to -1.60; I² not applicable; 1 RCT, participants = 84; very low quality evidence). There was insufficient evidence to determine whether the groups differed in rates of adverse events (RR 2.25, 95% CI 0.74 to 6.80; 1 RCT, participants = 94; very low quality evidence). No thromboembolic events were reported.TXA versus levonorgestrel intrauterine system (LIUS)TXA was associated with a higher median PBAC score than TXA (median difference 125.5 points; 1 RCT, participants = 42; very low quality evidence) and a lower likelihood of improvement (RR 0.43, 95% CI 0.24 to 0.77; 1 RCT, participants = 42; very low quality evidence). This suggests that if 85% of women improve with LIUS, 20% to 65% of women will do so with TXA. There was insufficient evidence to determine whether the groups differed in rates of adverse events (RR 0.83, 95% CI 0.25 to 2.80; 1 RCT, participants = 42; very low quality evidence). No thromboembolic events were reported.

AUTHORS' CONCLUSIONS

Antifibrinolytic treatment (such as TXA) appears effective for treating HMB compared to placebo, NSAIDs, oral luteal progestogens, ethamsylate, or herbal remedies, but may be less effective than LIUS. There were too few data for most comparisons to determine whether antifibrinolytics were associated with increased risk of adverse events, and most studies did not specifically include thromboembolism as an outcome.

Desmopressin (DDAVP), tranexamic acid and haemostasis

Desmopressin is a widely used haemostatic drug. In contrast to vasopressin, it has no pressor activity. The effect is immediate, with two to six-fold increases in the plasma concentrations of coagulation factor VIII, von Willebrand factor and tissue plasminogen activator, and of platelet adhesiveness. Desmopressin is used in patients with mild haemophilia A, von Willebrand's disease, congenital platelet dysfunction or acquired platelet dysfunction due to uraemia or such drugs as aspirin. Tranexamic acid is an antifibrinolytic agent effective against menorrhagia, epistaxis and bleeding after conization or oral surgery; its haemostatic effect in connection with major surgery is presently being evaluated.

Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates

Approximately half (51%) of the 6.6 million pregnancies in the US each year are unintended and half of those pregnancies (54%) occur among women not using contraception. Many women discontinue their contraceptives due to method dissatisfaction. Bothersome unscheduled bleeding is one of the main reasons cited by women for stopping a birth control method. Improving counseling and management of these side effects will aide in increasing satisfaction with contraceptive methods. The following review will discuss the bleeding profiles associated with the contraceptive options available in the US. A valuable resource from the Centers for Disease Control and Prevention, the US Selected Practice Recommendations for Contraceptive Use, will be introduced. Definitions of the types of unscheduled bleeding are included, as well as strategies for treatment for each contraceptive method. The evidence whether or not anticipatory counseling increases continuation rates will also be reviewed.

Efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding: a systematic review

OBJECTIVE

To evaluate the efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding.

DESIGN

Systematic review.

POPULATION

Women with a diagnosis of idiopathic and non-functional heavy menstrual bleeding treated with tranexamic acid.

METHODS

Electronic searches were conducted in literature databases up to February 2011 by two independent reviewers. We included all trials involving the efficacy of tranexamic acid for the treatment of heavy uterine bleeding. Pregnant, postmenopausal and cancer patients were excluded.

MAIN OUTCOME MEASURES

Effect of tranexamic acid treatment on objective reduction of menstrual bleeding and improvement in patient quality of life.

RESULTS

A total of 10 studies met our inclusion criteria. Available evidence indicates that tranexamic acid therapy in women with idiopathic menorrhagia resulted in 34-54% reduction in menstrual blood loss. Following tranexamic acid treatment, patient's quality-of-life parameters improved by 46-83%, compared with 15-45% for norethisterone treatment. When compared with placebo, tranexamic acid use significantly decreased the blood loss by 70% in women with menorrhagia secondary to an intrauterine device (p<0.001). Limited evidence indicated potential benefit in fibroid patients with menorrhagia. No thromboembolic event was reported in all studies analyzed.

CONCLUSIONS

Available evidence indicates that tranexamic acid treatment is effective and safe, and could potentially improve quality of life of patients presenting with idiopathic and non-functional heavy menstrual bleeding. Data on the therapeutic efficacy of tranexamic acid in patients with symptomatic fibroids are limited, and further studies are therefore needed.

Tranexamic acid therapy for heavy menstrual bleeding

INTRODUCTION

Heavy menstrual bleeding (HMB, also known as menorrhagia) is an important health problem that interferes with women's quality of life. It is one of the most common reasons why women are seen by their family doctors in primary care and is a condition frequently treated by surgery.

AREAS COVERED

This review covers the pharmacology of tranexamic acid in brief and concentrates on its use in the treatment of HMB. Papers published in the English language between January 1985 and November 2010 were reviewed using Medline, Embase, Cinahl and the Cochrane Database of Systematic Reviews. Search terms were 'heavy menstrual bleeding', 'tranexamic acid' and 'menorrhagia'.

EXPERT OPINION

Tranexamic acid, a competitive inhibitor of plasminogen activation, has been used to treat HMB for well over four decades. Although several treatment options are available for HMB, tranexamic acid is particularly useful in women who either desire immediate pregnancy or for whom hormonal treatment is inappropriate. Tranexamic acid is a well-tolerated, cost-effective drug that reduces menstrual blood loss in the range of 34-59%. It improves the health-related quality of life in women in HMB.

Copper containing intra-uterine devices versus depot progestogens for contraception

BACKGROUND

Highly effective contraception is essential to reduce unintended pregnancies and the effect these have on individuals, society and public health resources. Intrauterine devices (IUDs) and depot progestogens are two commonly used long-acting, reversible contraceptive methods with different risk and benefit profiles.

OBJECTIVES

To compare the contraceptive and non-contraceptive benefits and risks of using the copper-containing IUD versus depot progestogens for contraception.

SEARCH STRATEGY

In June 2009 we searched the Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Central Register of Controlled Trials, Pubmed, Popline, Clinical Trials.gov, the Current Controlled Trials metaRegister, EMBASE and LILACS, and contacted study authors.

SELECTION CRITERIA

Randomized trials comparing women using copper-containing IUDs with women using depot progestogens.

DATA COLLECTION AND ANALYSIS

We assessed eligibility and trial quality, extracted and double-entered data.

MAIN RESULTS

Two studies were included in the review. In the one study in HIV infected women, the IUD was compared with depot progestogen or the oral contraceptive, according to the women's choice. As the majority of women chose depot progestogen, we have included this study in the review, within a mixed hormonal contraception sub-group.Overall, the copper IUD was more effective than depot progestogens/hormonal contraception at preventing pregnancy (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.24 to 0.84). HIV disease progression was reduced in the IUD group (RR 0.58; 95% CI 0.39 to 0.87). There was no significant difference in pelvic inflammatory disease rates between the two groups. Discontinuation of the allocated method was less frequent with the IUD in one study, and less frequent with hormonal contraception in the other study (in which women were allowed to switch between various hormonal methods).

AUTHORS' CONCLUSIONS

In the populations studied, the IUD was more effective than hormonal contraception with respect to pregnancy prevention. High quality research is urgently needed to compare the effects, if any, of these two commonly used contraception methods on HIV acquisition/seroconversion and HIV/AIDS disease progression.

Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use

BACKGROUND

Heavy bleeding and pain are the most common reasons why women discontinue IUDs. Non-steroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis, have been shown to be effective in reducing menstrual bleeding and pain in women without IUDs.

OBJECTIVES

This review summarizes all randomized controlled trials studying use of nonsteroidal anti-inflammatory drugs for treatment of bleeding or pain associated with IUD use. Trials of prophylactic use of these drugs around the time of IUD insertion were also included.

SEARCH STRATEGY

We performed searches of PubMed, CENTRAL, POPLINE, EMBASE, LILACS, and CINAHL for relevant trials. We also wrote to the authors of all trials identified to seek other published or unpublished trials.

SELECTION CRITERIA

We included all randomized controlled trials in any language that tested one or more nonsteroidal anti-inflammatory drugs for treatment or prevention of bleeding or pain associated with IUD insertion or use.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from relevant trials, and we entered data into RevMan for analysis.

MAIN RESULTS

We found 15 trials from 10 countries; the total number of participants was 2702. Nonsteroidal anti-inflammatory drugs (naproxen, suprofen, mefenamic acid, ibuprofen, indomethacin, flufenamic acid, alclofenac, and diclofenac) were effective in reducing menstrual blood loss associated with IUD use. This held true for women with and without complaints of heavy bleeding. Similarly, these drugs were effective in reducing pain associated with IUD use. In contrast, prophylactic use of nonsteroidal anti-inflammatory drugs had mixed results; studies with ibuprofen found no effect on pain after insertion on IUD discontinuation. No important differences emerged in the one trial comparing the effect of different NSAIDs on bleeding.

AUTHORS' CONCLUSIONS

Nonsteroidal anti-inflammatory drugs reduce bleeding and pain associated with IUD use. NSAIDs should be considered first-line therapy; if NSAIDs are ineffective, tranexamic acid may be considered as second-line therapy. Prophylactic ibuprofen administration with the first six menses after insertion appears unwarranted.

FFPRHC Guidance (January 2004) The Copper Intrauterine Device as Long-term Contraception

This Guidance provides information for clinicians providing women with copper-bearing intrauterine devices as long-term contraception. A key to the grades of recommendations, based on levels of evidence, is given at the end of this document. Details of the methods used by the Clinical Effectiveness Unit (CEU) in developing this Guidance and evidence tables summarising the research basis of the recommendations are available on the Faculty website (www.ffprhc.org.uk). Abbreviations (in alphabetical order) used include: acquired immune deficiency syndrome (AIDS); actinomyces-like organisms (ALOs); automated external defibrillator (AED); blood pressure (BP); British National Formulary (BNF); confidence interval (CI); copper-bearing intrauterine contraceptive device (IUD); emergency contraception (EC); Faculty Aid to Continuing Professional Development Topic (FACT); levonorgestrel-releasing intrauterine system (IUS); human immunodeficiency virus (HIV); Medicines and Healthcare products Regulatory Agency (MHRA); non-steroidal antiinflammatory drugs (NSAIDs); odds ratio (OR); pelvic inflammatory disease (PID); relative risk (RR); Royal College of Obstetricians and Gynaecologists (RCOG); Scottish Intercollegiate Guidelines Network (SIGN); sexually transmitted infection (STI); termination of pregnancy (TOP); World Health Organization (WHO); WHO Medical Eligibility Criteria (WHOMEC); WHO Selected Practice Recommendations (WHOSPR).

Tranexamic acid: a review of its use in the management of menorrhagia

Tranexamic acid (Transamin), Cyklokapron, Exacyl, Cyklo-f) is a synthetic lysine derivative that exerts its antifibrinolytic effect by reversibly blocking lysine binding sites on plasminogen and thus preventing fibrin degradation. In a number of small clinical studies in women with idiopathic menorrhagia, tranexamic acid 2-4.5 g/day for 4-7 days reduced menstrual blood loss by 34-59% over 2-3 cycles, significantly more so than placebo, mefenamic acid, flurbiprofen, etamsylate and oral luteal phase norethisterone at clinically relevant dosages. Intrauterine administration of levonorgestrel 20 microg/day, however, produced the greatest reduction (96% after 12 months) in blood loss; 44% of patients treated with levonorgestrel developed amenorrhoea. Tranexamic acid 1.5 g three times daily for 5 days also significantly reduced menstrual blood loss in women with intrauterine contraceptive device-associated menorrhagia compared with diclofenac sodium (150 mg in three divided doses on day 1 followed by 25 mg three times daily on days 2-5) or placebo. Tranexamic acid, mefenamic acid, etamsylate, flurbiprofen or diclofenac sodium had no effect on the duration of menses in the studies that reported such data. In a large noncomparative, nonblind, quality-of-life study, 81% of women were satisfied with tranexamic acid 3-6 g/day for 3-4 days/cycle for three cycles, and 94% judged their menstrual blood loss to be 'decreased' or 'strongly decreased' compared with untreated menstruations. The most commonly reported drug-related adverse events are gastrointestinal in nature. The total incidence of nausea, vomiting, diarrhoea and dyspepsia in a double-blind study was 12% in patients who received tranexamic acid 1g four times daily for 4 days for two cycles (not significantly different to the incidence in placebo recipients). In conclusion, the oral antifibrinolytic drug tranexamic acid is an effective and well tolerated treatment for idiopathic menorrhagia. In clinical trials, tranexamic acid was more effective at reducing menstrual blood loss than mefenamic acid, flurbiprofen, etamsylate and oral luteal phase norethisterone. Although it was not as effective as intrauterine administration of levonorgestrel, the high incidence of amenorrhoea and adverse events such as intermenstrual bleeding resulting from such treatment may be unacceptable to some patients. Comparative studies of tranexamic acid with epsilon - aminocaproic acid, danazol and combined oral contraceptives, as well as long-term tolerability studies, would help to further define the place of the drug in the treatment of menorrhagia. Nevertheless, tranexamic acid may be considered as a first-line treatment for the initial management of idiopathic menorrhagia, especially for patients in whom hormonal treatment is either not recommended or not wanted.

Menorrhagia: an update

Menorrhagia is defined as a 'complaint of heavy cyclical menstrual bleeding occurring over several consecutive cycles'. Objectively it is a total menstrual blood loss equal to or greater than 80 ml per menstruation. It is estimated that approximately 30% of women complain of menorrhagia. Excessive bleeding is the main presenting complaint in women referred to gynecologists and it accounts for two-thirds of all hysterectomies, and most of endoscopic endometrial destructive surgery. Thus, menorrhagia is an important healthcare problem. Its etiology, investigation, medical and surgical management are described. In approximately 50% of cases of menorrhagia no pathology is found at hysterectomy. Abnormal levels of prostaglandins or the fibrinolytic system in the endometrium have been implicated. Effective medical treatments suitable for long-term use include intrauterine progestogens, antifibrinolytic agents (tranexamic acid) and nonsteroidal anti-inflammatory agents (mefenamic acid). Over the past decade there has been increasing use of endometrial destructive techniques as an alternative to hysterectomy. Their further refinement and the advent of fibroid embolization has increased the options available to women.

The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review

OBJECTIVE

To determine whether the levonorgestrel-releasing intrauterine device (LNG-IUS), licensed at present for contraceptive use, may reduce menstrual blood loss with few side effects. If effective, surgery could be avoided with consequent resource savings.

METHODS

A systematic review addressing the effectiveness and cost effectiveness of the LNG-IUS for menorrhagia was undertaken.

RESULTS

Five controlled trials and five case series were found which measured menstrual blood loss. Nine studies recorded statistically significant average menstrual blood loss reductions with LNG-IUS (range 74%-97%). Another showed reduction in menstrual disturbance score. The LNG-IUS was more effective than tranexamic acid, but slightly less effective than endometrial resection at reducing menstrual blood loss. In one study, 64% of women cancelled surgery at six months, compared with 14% of control group women. In another, 82% were taken off surgical waiting lists at one year. No cost effectiveness studies were found.

DISCUSSION

Small studies of moderate quality indicate the LNG-IUS is an effective treatment for menorrhagia. Costs may be less than for tranexamic acid in primary and secondary care. Although its use may reduce surgical waiting lists, cost effectiveness assessment requires longer follow up.

CONCLUSION

Effectiveness and cost effectiveness relative to other treatments and the effect on surgical waiting lists can only be established in larger trials measuring patient-centred outcomes in women with menorrhagia.

Antifibrinolytics for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important cause of ill health in women. Medical therapy, with the avoidance of possibly unnecessary surgery, is an attractive treatment option. A wide variety of medications are available to reduce heavy menstrual bleeding but there is considerable variation in practice and uncertainty about the most appropriate therapy. Plasminogen activators are a group of enzymes that cause fibrinolysis (the dissolution of clots). An increase in the levels of plasminogen activators has been found in the endometrium of women with heavy menstrual bleeding compared to those with normal menstrual loss. Plasminogen activator inhibitors (antifibrinolytic agents) have therefore been promoted as a treatment for heavy menstrual bleeding. There has been a reluctance to prescribe tranexamic acid due to possible side effects of the drugs such as an increased risk of thrombogenic disease (deep venous thrombosis). Long term studies in Sweden, however, have shown that the rate of incidence of thrombosis in women treated with tranexamic acid is comparable with the spontaneous frequency of thrombosis in women.

OBJECTIVES

To determine the effectiveness of antifibrinolytics in achieving a reduction in heavy menstrual bleeding.

SEARCH STRATEGY

All studies which might describe randomised controlled trials of antifibrinolytic therapy for the treatment of heavy menstrual bleeding were obtained by electronic searches of the MEDLINE 1966-1997, EMBASE 1980-1997 and the Cochrane Library. Companies producing antifibrinolytics and experts within the field were contacted for reference lists and information on unpublished trials.

SELECTION CRITERIA

Randomised controlled trials in women of reproductive age treated with antifibrinolytic agents versus placebo, no treatment or any other medical (non-surgical) therapy for regular heavy menstrual bleeding within either the primary, family planning or specialist clinic settings. Women with post menopausal bleeding, intermenstrual bleeding, iatrogenic or pathological causes of heavy menstrual bleeding were excluded.

DATA COLLECTION AND ANALYSIS

Fifteen eligible trials were assessed by three reviewers and eight of these did not meet with the inclusion criteria. Of the seven remaining trials, four of these could be included within the meta-analysis. The remaining three trials had a crossover design and despite contacting the authors and appropriate companies, we were unable to extract the results in a format suitable to include these within the meta-analysis. However the results are included within the text of the review for discussion.

MAIN RESULTS

Antifibrinolytic therapy compared to placebo showed a significant reduction in mean blood loss (WMD -94.0 [-151.4, -36.5]) and significant change in mean reduction of blood loss (WMD -110.2 [-146. 5, -73.8]). This objective improvement was not mirrored by a patient perceived improvement in monthly menstrual blood loss (RR 2.5 [0.9, 7.3]) in the one study which recorded this outcome ( approximately approximately Edlund 1995 approximately approximately ). Antifibrinolytic agents were compared to only three other medical (non-surgical) therapies: mefenamic acid, norethisterone administered in the luteal phase and ethamsylate. In all instances, there was a significant reduction in mean blood loss (WMD -73.0 [-123.4, -22.6], WMD -111.0 [-178.5, -43.5] and (WMD -100 [-143.9, -56.1] respectively) and a strong, although non-significant trend in favour of tranexamic acid in the participants' perception of an improvement in menstrual blood loss. There were no significant differences in the frequency of reported gastrointestinal side effects with tranexamic acid when compared to either NSAIDs (RR 0.9 [0.4, 2.1], oral luteal phase progestagens (RR 0.4 [0.1, 1.2]) or ethamsylate (RR 0.88 [0.3, 2.9]) when these treatments were used for heavy menstrual bleeding. (ABSTRACT TRUNCATED)

Menorrhagia in von Willebrand disease successfully treated with single daily dose tranexamic acid

Four cases of menorrhagia in von Willebrand disease were successfully treated with tranexamic acid given in a single daily dose of 4 g for the first 3-5 days of the menstrual cycle. The pathophysiology and pharmacokinetics are discussed. The apparent improved efficacy and acceptability of this new dosing regime have been highlighted.

Management of abnormal uterine bleeding

Patients treated for dysfunctional uterine bleeding are separated into two groups: those with acute bleeding episodes and those with chronic repetitive bleeding problems. An acute bleeding episode is best controlled with the use of high-dose estrogen. A curettage is indicated for patients with acute bleeding resulting in hypovolemia, and a curettage or hysteroscopically directed biopsies is indicated for women with risk factors for endometrial cancer who have persistent bleeding problems. The management of anovulatory dysfunctional uterine bleeding is determined by the needs of the patient. In the adolescent medroxyprogesterone acetate is administered orally once a day for 10 days each month for > or = 3 months, and the patient is monitored closely thereafter. Oral contraceptives are used for women of reproductive age with anovulatory bleeding episodes who also require contraception. Clomiphene citrate is used for women of reproductive age with anovulatory bleeding who want to conceive. Oral medroxyprogesterone acetate is administered 10 days each month for 6 months for the treatment of anovulatory dysfunctional uterine bleeding alone in this age group. For the perimenopausal patient dysfunctional uterine bleeding may be treated by the administration of cyclic progestin or cyclic conjugated equine estrogens for 25 days with the concomitant administration of medroxyprogesterone acetate for days 18 to 25. The perimenopausal patient with dysfunctional uterine bleeding who is a nonsmoker and does not have evidence of vascular disease may also be treated with low-dose combination oral contraceptives. The long-term treatment for women with ovulatory dysfunctional uterine bleeding is the most difficult type of dysfunctional uterine bleeding to manage. The long-term therapy is directed at the reduction in menstrual blood loss. For these patients prolonged progestin use, oral contraceptives, nonsteroidal antiinflammatory drugs, antifibrinolytic agents, danazol, and as a last resort gonadotropin-releasing hormone agonists are part of the therapeutic armamentarium. A combination of two or more of these agents is often required to successfully control the abnormal bleeding. For patients who no longer desire future fertility and have associated pelvic pathologic disorders or for those who fail all medical regimens, surgical therapy may be considered. Either hysterectomy or endometrial ablation has been used. Patients with von Willebrand's disease and excessive menstrual blood loss may be misdiagnosed as having dysfunctional uterine bleeding. van Willebrand's disease is the most common bleeding disorder and is present in approximately 1% of the population. It is much more common than previously recognized. There are improved diagnostic tests to identify this disorder and, most important, there is a high-concentration desmopressin acetate nasal spray available as treatment that does not involve the risk of transmission of hepatitis and human immunodeficiency virus.

Modern intra-uterine devices

Modern intrauterine devices (IUDs) provide effective, safe and long-term contraception and could be recommended to most women. The mechanism of action of an IUD is still not fully understood, but most recent research suggests that copper-IUDs as well as hormone-releasing intrauterine systems (IUSs) prevent conception. In women in mutually monogamous relationships the risk of PID is low and related to the insertion procedure. IUD/IUS use should be discouraged if there is a suspicion of increased risk of sexually transmitted disease. The risk of ectopic pregnancy is extremely low if modern, highly effective IUDs/IUSs are used. Copper-IUDs increase menstrual blood loss by around 50%, whereas hormone-releasing IUSs substantially reduce menstrual blood loss. Careful patient selection and counselling are the most important tools in order to provide acceptable and safe IUD use.

Reduction of menstrual blood loss in women suffering from idiopathic menorrhagia with a novel antifibrinolytic drug (Kabi 2161)

OBJECTIVE

To compare the effect of Kabi 2161 (a prodrug of tranexamic acid) and placebo on the reduction of menstrual blood loss in women suffering from idiopathic menorrhagia and to evaluate tolerance and effectiveness in a two-dose regimen.

DESIGN

A randomised, double blind parallel group study using double dummy technique.

SETTING

The departments of gynaecology at three medical centres in Sweden.

SUBJECTS

Ninety-one outpatients visiting the gynaecological clinics from March 1991 to May 1992 were randomised into the study; 68 women fulfilled the study.

INTERVENTIONS

Two run-in cycles, followed by administrations of Kabi 2161 (600 mg) tablets (1 four times daily or 2 twice daily) or placebo for the first five days of three menstrual cycles.

MAIN OUTCOME MEASURES

Objective measurement of the change in menstrual blood loss during the treatment periods compared with menstrual blood loss during the run-in periods.

RESULTS

A statistically significant reduction of menstrual blood loss was found for each treatment group, compared with the placebo group (P < 0.001). The mean reduction with 95% confidence interval (CI) was 33% (24-40) in the group treated with 1 four times daily and 41% (33-49) in the group treated 2 twice daily. The difference between the treated groups in reduction of menstrual blood loss is not significant. No significant differences were found in the frequencies of reported unwanted events during run-in and during treatment between the different treatment groups. There were also no significant differences between the treatment groups and the placebo group.

CONCLUSION

Kabi 2161 in a dosage of 2.4 g per day gave a statistically significant reduction in objectively measured menstrual blood loss in a two (41%) as well as in a four (33%) dosage regimen compared with placebo. Frequency of unwanted events did not differ from those during run-in or from those in the placebo group. The optimal daily dosage needs to be further evaluated in a dose titration study.

Haemostatic mechanism in the endometrium: role of cyclo-oxygenase products and coagulation factors

1. The primary mechanism of haemostasis in the endometrium of rat was studied and results were compared to that in the mesenteric artery. 2. The bleeding time of the rat endometrium as assessed by haemoglobin output was significantly decreased after pretreatment of the animals with either indomethacin (5 mg kg-1, i.v.) or meclofenamate (3 mg kg-1, i.v.) whereas the bleeding time was significantly increased in the rat mesenteric artery. 3. The bleeding time of the rat endometrium was unchanged from control values following treatment with prostacyclin (0.5 microgram kg-1 min-1, i.v.) or 1-benzylimidazole (50 mg kg-1, i.v.) whereas the bleeding times were increased in the rat mesentric artery. 4. Administration of heparin (100 units kg-1) increased the bleeding time in the rat mesenteric artery but had no effect on the bleeding time of the endometrium. 5. Superfusion of the endometrium with 16, 16-dimethyl PGE2 (1 microgram ml-1) a vasodilator, increased the bleeding time of the endometrium but superfusion of PGE2 over the mesenteric artery did not affect the bleeding time from this site. 6. Histological studies of the mesenteric artery and the endometrium following haemostatis revealed that the haemostatic plug in the mesenteric artery was mainly composed of platelets and fibrin whereas in the endometrium it was mainly composed of fibrin. 7. These findings suggest that haemostasis in the endometrium may be mediated by the vascular tone and fibrin whereas formation of the platelet plug may be primary mechanism for haemostasis in the mesenteric artery.

Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice

Menorrhagia can be treated by drug therapy or surgery. General practitioners (GPs) can prescribe drugs to reduce menstrual blood loss as first-line treatment, referring patients for surgical treatment if drug therapy fails. This study examined the efficacy of drugs used to treat menorrhagia and surveyed British GPs to discover the extent to which they prescribed the most effective drugs for this condition. The results suggest that treatment of this condition in primary care falls short of desirable standards. A meta-analysis of randomized trials of drug therapy revealed wide differences in efficacy and side effects. The most effective drug (tranexamic acid) is little used by British GPs, whereas the least effective drug (norethisterone) is the most frequently prescribed.

Prostaglandin synthesis inhibitors in menorrhagia, intrauterine contraceptive device-induced side effects and endometriosis

Primary menorrhagia, IUD side effects and endometriotic symptoms may be a result of excessive PG release in the reproductive organs. These conditions and symptoms can be prevented or markedly alleviated by a PG synthesis inhibitor, such as tolfenamic acid. This treatment, which is used only intermittently, has been well tolerated with no serious side effects.

The morphologic changes of endometrial spiral arterioles in IUD-induced menorrhagia

To investigate the relationship between IUD-induced menorrhagia and spiral arteriolar function, we examined the endometrium under light and electron microscope on samples obtained within 24 hours after the onset of premenstrual spotting. These samples included an IUD bleeding group (20 cases), an IUD non-bleeding group (20 cases) and an IUD non-user group (10 cases) as controls. Compared with the IUD non-user group the degenerative changes of spiral arteriolar wall were more severe and dilation of the spiral arteriolar lumen was more obvious, especially in the spongeous layer. In the IUD non-user group these changes were mild, suggesting that IUD-induced menorrhagia might be correlated with poor contractility of spiral arterioles in the spongeous layer.

Assessment of medical treatments for menorrhagia

Although usually not life-threatening, dysfunctional uterine bleeding (DUB) can cause discomfort and disruption to life for many women. It has been poorly researched in the past, primarily because of difficulties in trying to accurately measure blood loss and response to treatment. There are several different therapies currently available but, for many, actual evidence of their efficacy is lacking from scientific data. Progestogens are the most frequently prescribed drugs for the treatment of DUB. Data support their use in anovulatory women but a number of comparative trials have shown that an overall reduction in blood loss of only 20% is achieved in ovulatory women. Their use, therefore, must be questioned as the first line of treatment. Combined oral contraceptives were at one time popular but whether the low-dose, current generation pills are equally effective awaits appropriate trials. Prostaglandin synthetase inhibitors can be useful, with up to a third of women with menorrhagia benefiting from a reduction of between 25% and 35% in blood loss. A proportionally greater reduction is seen in women with more excessive bleeding. Antifibrinolytic drugs have been shown to reduce menstrual blood loss in DUB by 50% and would be useful in women in whom oestrogens are contraindicated. Gonadotrophin-releasing hormone analogues are highly effective because of their ability to induce amenorrhoea, but long-term use is contraindicated because of their hypo-oestrogenic effects. One other effective therapy for menorrhagia has been danazol.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine contraceptive device in the treatment of idiopathic menorrhagia

Treatment with flurbiprofen (100 mg twice a day for 5 days), tranexamic acid (1.5 gm three times a day for 3 days and 1 gm twice a day for another 2 days), and an intrauterine contraceptive device releasing 20 micrograms levonorgestrel per day was compared in women with idiopathic menorrhagia. The menstrual blood loss during two control periods in 15 women subsequently treated with flurbiprofen and tranexamic acid was 295 +/- 52 ml and 203 +/- 25.2 ml in the 16 women later fitted with a levonorgestrel-releasing intrauterine contraceptive device. Menstrual blood loss was reduced by all three forms of treatment. The reduction in menstrual blood loss expressed as a percentage of the mean of two control cycles for each form of treatment was as follows: flurbiprofen, 20.7% +/- 9.9%; tranexamic acid, 44.4% +/- 8.3%; levonorgestrel-releasing intrauterine contraceptive device after 3 months, 81.6% +/- 4.5%; levonorgestrel-releasing intrauterine contraceptive device after 6 months, 88.0% +/- 3.1%; levonorgestrel-releasing intrauterine contraceptive device after 12 months, 95.8% +/- 1.2%. The reduction in menstrual blood loss achieved by the levonorgestrel-releasing intrauterine contraceptive device was greater than that recorded with flurbiprofen (p less than 0.001) and tranexamic acid (p less than 0.01), and was greater for tranexamic acid when compared with flurbiprofen (p less than 0.05). The levonorgestrel-releasing intrauterine contraceptive device was the only form of treatment to reduce mean menstrual blood loss below 80 ml per menstruation, the upper limit of normal menstrual blood loss.

Randomized trial of 2 hormonal and 2 prostaglandin-inhibiting agents in women with a complaint of menorrhagia

A series of 45 ovulatory women with a complaint of menorrhagia were randomized into 3 treatment groups, before receiving therapy with mefenamic acid in 2 cycles and 1 of 3 other agents in 2 cycles: naproxen (group 1; n = 14), a low dose monophasic combined oral contraceptive (group 2; n = 12) or low dose danazol (group 3; n = 12). Menstrual blood loss was measured in 2-4 control cycles and during therapy. Mefenamic acid reduced measured blood loss by 20%; 38%; and 39% in groups 1-3 respectively. Naproxen reduced blood loss by 12%; the oral contraceptive by 43%; and danazol by 49%. There was no statistically significant difference in blood loss reduction (mean of 2 cycles) between any of the treatments, although women on danazol experienced a dramatic and highly significant further reduction in blood loss after the first treatment cycle (p less than 0.003). These were all effective therapies in a majority of women, but some 'non-responders' were seen in each group. The 'non-responders' had a significantly lower pretreatment blood loss than responders. Several women in group 1 showed anomalous responses to prostaglandin inhibitors with consistent and substantial exacerbation of menorrhagia during therapy. A number of reasonable therapies exist for the medical treatment of menorrhagia, but because none is suitable for everyone management needs to be individualized for each patient.

Dysfunctional uterine bleeding

The diagnosis of DUB is made by the exclusion of organic disease as a cause of the abnormal menses; the condition accounts for about 80% of cases of menorrhagia. Of these, over 80% will have no abnormality of the hypothalamo-pituitary-ovarian axis, and it is likely that the disorder is the result of local endometrial factors. There appears to be not only a preponderance of vasodilatory prostaglandins in the endometrium of women with menorrhagia, but also an excessive increase in fibrinolytic activity within the uterine cavity. Once a diagnosis has been reached with the aid of history, examination, haematological and endocrine investigations, and dilatation and curettage when appropriate, medical treatment is the usual first line approach. Non-steroidal anti-inflammatory drugs such as mefenamic acid, or antifibrinolytic agents such as tranexamic or epsilon aminocaproic acids, will reduce blood loss by between 25 and 50%. Though the former drugs are relatively free from side-effects in healthy women, intracranial thrombosis has been reported with the latter (Agnelli et al, 1982). Medications which suppress ovarian function, such as danazol or gonadotrophin releasing hormone analogues, are highly effective in lessening, or inhibiting, menstrual loss, but at the expense of side-effects and convenience respectively. The combined contraceptive pill may reduce blood loss by 50% but is not appropriate for older women. Cyclical gestagens such as norethisterone have been widely employed, particularly for the treatment of anovulatory cycles, but their place in the management of ovulatory DUB is less clear. If medical treatment fails hysterectomy should be considered, though less invasive surgical methods of endometrial ablation are being developed. Finally, it should be remembered that in the absence of associated signs or symptoms of iron-deficiency anaemia, heavy menstrual bleeding is a subjective complaint and up to 50% of women describing menorrhagia will have a measured monthly blood loss within normal limits.

Treatment of menorrhagia with meclofenamate sodium

A double-blind, placebo-controlled crossover trial was undertaken to determine the efficacy of meclofenamate sodium in the treatment of menorrhagia. Twenty-nine patients who had a baseline menstrual blood loss greater than 60 ml received 2 months' each of meclofenamate sodium, 100 mg by mouth, three times a day, or a placebo. The mean menstrual blood loss was reduced from 141.6 +/- 15.9 ml at baseline to 69.0 +/- 6.3 ml during treatment cycles but remained increased during placebo cycles (135.6 +/- 11.3 ml). The symptoms of dysmenorrhea, backache, and headache were significantly reduced only during active drug periods. The number of days of flow and pads or tampons used was also reduced during drug cycles but not during placebo cycles. Overall, 26 of the 29 patients evaluated had a reduction in menstrual blood loss with the use of meclofenamate sodium. It appears that many women with unexplained menorrhagia may benefit from this treatment.

The effects of danazol, mefenamic acid, norethisterone and a progesterone-impregnated coil on endometrial prostaglandin concentrations in women with menorrhagia

The effects of four medical treatments have been assessed on menstrual blood loss (MBL) and endometrial prostaglandin (PG) concentrations in 30 women with objectively confirmed menorrhagia. Patients were randomly treated with danazol, 200 mg daily (n = 6), mefenamic acid, 500 mg three times daily during menses (n = 8), norethisterone, 5 mg twice daily from day 15-25 of the cycle (n = 8) or a progesterone-impregnated coil releasing 65 micrograms progesterone daily (n = 8). Endometrial biopsies were obtained in the mid-luteal phase before and after treatment in 23 cases, and assayed for PG content using radioimmunoassay. Treatment with norethisterone had no effect on either MBL or the concentration of PGs in the endometrium. MBL was significantly reduced after treatment with mefenamic acid (P = 0.05, n = 6) and the progesterone coil (P less than 0.05, n = 6), and was reduced in each of 4 cases treated with danazol in whom endometrial biopsies were available. Although there was no consistent change in endometrial PG concentrations in either the mefenamic acid or danazol groups, the lower MBL after insertion of the progesterone coil was associated with a reduced endometrial content of PGE, PGF2 alpha and "total" PG (6oxo PGF1 alpha + PGE + PGF2 alpha)-P = 0.05. Whereas the cyclooxygenase inhibitor mefenamic acid is likely to exert its effect on endometrial PGs at the time of menstruation itself, the continuous administration of progesterone throughout the menstrual cycle could result in both an impairment in estrogen receptor generation leading to reduced estrogen-mediated cyclooxygenase activity, and an increase in endometrial PG metabolism.

Treatment of increased menstrual blood loss in IUD users

Although bleeding problems represent the commonest side effect of IUDs and an important medical reason for discontinuation of use, its pathogenesis still remains incompletely understood and a standard universally acceptable therapy is not yet available. Proper insertion, change in size, material or shape of the IUD, as well as custom fitting to avoid dimensional incompatibilities, did not significantly improve the IUD-associated bleeding problems. Addition of copper to inert devices seemed to slightly improve the bleeding by reducing the antifibrinolytic activity but probably more was achieved through reducing the device size. Hormone-releasing devices appear to reduce the amount of bleeding significantly but a post-insertion phase of irregular spotting is a common complaint. Locally released antifibrinolytic agents were tried in limited investigations but a short period of drug release restricted further evaluation. Systemic administration of antifibrinolytic agents and non-steroidal anti-inflammatory drugs hold promise for the control of IUD-induced menorrhagia. The duration of bleeding and intermenstrual spotting still remains an unresolved clinical problem that requires further evaluation. This area of clinical concern in IUD use needs more in depth understanding and testing of new agents, particularly in the area of local release of antihemorrhagic agents.

Ibuprofen prevents IUCD-induced increases in menstrual blood loss

To study the effects of a copper-releasing intrauterine contraceptive device (IUCD) and a prostaglandin (PG) synthesis inhibitor, ibuprofen, on menstrual blood loss, 28 healthy women received either a Fincoid 350 or a ML Cu375 device and were then treated in a double-blind randomized manner with ibuprofen (1200 mg daily) or a placebo during their next three menstruations. The preinsertion menstrual blood loss (2 cycles) was normal for healthy women (median 38 ml) with no difference between women who subsequently received either Fincoid 350 or ML Cu375 and ibuprofen or placebo treatment. The median increase in menstrual blood loss after the insertion of an IUCD was 74% (P less than 0.01) in women receiving placebo treatment, and this rise was not dependent on the type of IUCD. Ibuprofen treatment prevented the increase in blood loss following IUCD insertion, but it failed to shorten the duration of menstruation. Four women reported side-effects (tiredness, irritability, sweating, dyspepsia) during ibuprofen treatment, and two women did so during placebo treatment. It is concluded that IUCDs with a large copper surface also increase menstrual blood loss, but that this increase can be prevented with ibuprofen treatment.

Prostacyclin and thromboxane in gynecology and obstetrics

The gynecologic and obstetric implications of the smooth muscle-relaxing, antiaggregatory prostacyclin and its endogenous antagonist, thromboxane A2, are reviewed. In addition to the vascular wall and circulating platelets, which are primary sources for prostacyclin and thromboxane A2, respectively, reproductive tissues produce great amounts of these prostanoids, evidently for the regulation of the vascular tone and/or vascular platelet interaction. Several gynecologic and obstetric disorders are characterized by abnormalities in prostacyclin and/or thromboxane A2. In primary menorrhagia the uterine release of prostacyclin is increased, and consequently menstrual blood loss can be reduced with various prostaglandin synthesis inhibitors. Prostacyclin relaxes the nonpregnant myometrium in vitro and may also do so in vivo, although intravenous infusion of prostacyclin has no effect upon the uterine contractility in nonpregnant or pregnant subjects. Patients with pelvic endometriosis may have increased levels of prostacyclin and thromboxane A2 metabolites in the peritoneal fluid. The prostacyclin/thromboxane A2 balance shifts to thromboxane A2 dominance in patients with gynecologic cancer. During pregnancy the production of prostacyclin and thromboxane A2 increases in the mother and fetoplacental tissue. Preeclampsia and other chronic placental insufficiency syndromes are accompanied by prostacyclin deficiency in the mother and in fetomaternal tissues and by an overproduction of thromboxane A2, at least in the placenta. These changes may account for the vasoconstriction and platelet hyperactivity, which are pathognomonic for hypertensive pregnancies. By directing the prostacyclin/thromboxane A2 balance to prostacyclin dominance (by dietary manipulation, administration of prostacyclin and/or its analogues, drugs with prostacyclin-stimulating and/or thromboxane A2-inhibiting action), it may be possible to prevent and/or treat hypertensive pregnancy complications in the future.