A birth control device may also help to control excessive menstrual bleeding, new research suggests. The study compared an intrauterine device (IUD) with standard treatments. The type of IUD used releases the hormone levonorgestrel inside the uterus. It is sold under the brand name Mirena. Many women using the hormonal IUD for birth control have found that it reduces menstrual bleeding. The new study included nearly 600 women. All of them had very heavy menstrual bleeding, called menorrhagia. The women were randomly divided into 2 groups. One group received the hormonal IUD. The other group received standard treatments with hormones or medicines. After 2 years, 64% of women were still using the hormonal IUD. Only 38% were still using the other treatments. Women who stopped most often said their treatment did not work or caused side effects. Women using the hormonal IUD also reported more improvements in symptoms and better quality of life than those in the other group. The New England Journal of Medicine published the study. HealthDay News wrote about it January 9.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Excessive menstrual bleeding is a common complaint. It accounts for about 20% of visits to gynecologists in the United States and the United Kingdom. In the U.K., about 5% of women between the ages of 20 and 49 see a family doctor each year for excessive blood flow during periods. Many women have surgery for this problem. The medical term for it is menorrhagia.

"Excessive blood flow" can be tricky to define. A common definition for research is more than 80 milliliters (2.7 fluid ounces) per menstrual cycle. But actual measurement is difficult. More recent guidelines rely on the woman's quality of life and whether the heavy periods disrupt her emotional, social or physical well-being.

Treatment options include:

• Tranexamic acid, a drug that encourages blood to clot
• Mefenamic acid, a medicine that blocks production of a substance (called prostaglandin) involved in menstrual bleeding
• Hormones, such as progesterone, or estrogen plus a progestogen, to help regulate bleeding
• Surgery to remove the lining of the uterus or the uterus itself (hysterectomy)

Surgery usually is not a first choice. But in many cases it's not clear which of these options is best. In the United States, most women are treated with hormones or surgery. But it's common to try one treatment after another because the first one doesn't work. Unfortunately, little research has been done to guide doctors' treatment advice.

That's why a new study is important. The New England Journal of Medicine published the study. It compared usual medical care with a hormonal treatment placed in the uterus. It's called a levonorgestrel-releasing intrauterine system. Originally developed as a birth control method, the system is a type of intrauterine device (IUD) that releases hormones. It also reduces menstrual blood flow. The hormonal IUD is sold under the brand name Mirena.

The study found that women assigned to treatment with the IUD:

• Had a significant reduction in symptoms over 6 months
• Reported a bigger reduction in symptoms than those in the usual treatment group (although usual treatment was also effective)
• Continued to have improved symptoms for at least 2 years
• Reported improvements in:
  
  • Social and family life
  • Work and daily routine
  • Psychological and physical health

About 64% of the women assigned to the hormonal IUD group were still using the treatment after 2 years. Only 38% of those assigned to usual medical care were still using those treatments after 2 years. The other women stopped because their treatment didn't work or caused side effects. Serious side effects were rare and similar in both groups.

These results are promising and suggest that increased use of the hormonal IUD could improve the lives of millions of women. However, more than one-third of women in this study decided to have the hormonal IUD removed. So it appears that this is not the last word on the treatment of menorrhagia.

What Changes Can I Make Now?

It's not always easy to sort out "normal" heavy periods from menorrhagia. The latter is suggested by bleeding so heavy that you:

• Have to change a pad every hour for at least three hours
• Have to get up during the night to change a pad
• Pass large clots
• Develop anemia from blood loss

As mentioned above, it's also important to assess the impact of heavy menstrual bleeding on your life. You may have menorrhagia if heavy bleeding impairs your social, physical or emotional life.

Your doctor can discuss treatment options with you and also look for a cause. Possible causes include:

• An imbalance of hormones
• Something abnormal in the uterus (such as common, non-cancerous tumor called a fibroid)
• An abnormal clotting system

Don't assume that you just have to put up with heavy periods. The cause may be reversible (such as a fibroid). or may respond dramatically to treatment.

What Can I Expect Looking to the Future?

This new research may lead to increased use of the hormonal IUD in the future. It's already approved in the United States for women with heavy bleeding who also want to use it for birth control. The device is marketed here under the brand name Mirena. But this new study could lead to its approval even for women who do not need birth control.

You can expect to hear about the results of more research on the hormonal IUD. This new study lasted two years. But heavy menstrual bleeding often lasts much longer. Therefore, we'll need to know more about whether the device is safe and effective over the longer term.

I hope that more research will lead to a better understanding of why some women develop menorrhagia while others do not. Better insight into the cause (or causes) should lead to even more effective treatments.