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Contraception - Management
How does menorrhagia, fibroids, or previous ectopic pregnancy influence choice?

  • Women with idiopathic menorrhagia
    • Methods that can be used without restriction: combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring, and the levonorgestrel-releasing intrauterine system (IUS) (initiation), which all may reduce menstrual blood loss; sterilization.
    • Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill (POP), progestogen-only injectables and implants, copper intrauterine devices (IUDs), the levonorgestrel-releasing IUS (continuation of use), barrier methods, and natural family planning methods (if the cycle is regular; if the cycle is irregular, a new user would find it more difficult to learn the method).
    • Consider:
      • The levonorgestrel IUS (Mirena®) as the first-line contraceptive option (licensed indication).
      • The COC as the second line contraceptive option.
      • The POP and progestogen-only injectables as third line contraceptive options.
    • For information on non-contraceptive treatments, see the CKS topic on Menorrhagia.
  • Women with a history of ectopic pregnancy
    • All methods can be used without restriction.
    • However, methods of contraception that inhibit ovulation (i.e. COCs, progestogen-only injectables and implants) are particularly suitable, as they reduce ectopic pregnancy to a greater degree compared with other methods.
  • Women with uterine fibroids
    • Without distortion of the uterine cavity: all methods can be used without restriction.
    • With distortion of the uterine cavity: copper IUDs and the levonorgestrel-releasing IUS should not be used if they cannot be easily fitted. All other methods can be used without restriction.
Basis for recommendation
  • These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FSRH, 2009b], and the National Institute for Health and Clinical Excellence [NICE, 2007b].
  • Pharmacological treatments for heavy menstrual bleeding
    • NICE recommends that pharmacological treatments be considered in the following order:
      • Levonorgestrel-releasing intrauterine system (IUS) — provided long-term (at least 12 months) use is anticipated.
      • Tranexamic acid, or nonsteroidal anti-inflammatory drugs (NSAIDs), or combined oral contraceptives (COCs).
      • Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens [NICE, 2007b].

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