Combined hormonal contraception

Combined hormonal contraception (either a combined oral contraceptive (COC) or the contraceptive vaginal ring) is less effective than the 52 mg LNG-IUD, but is an effective second-line option for heavy menstrual bleeding. There is less evidence for the contraceptive vaginal ring than for COCs, but it is likely to be of similar benefit to COCs. A combination of estradiol valerate with dienogest has an indication for heavy or prolonged menstrual bleeding but there is insufficient data to recommend it over other formulations as there are no head-to-head studies.

Extended or continuous use of combined hormonal contraception can minimise withdrawal bleeding, and is recommended for heavy menstrual bleeding.

For treatment of heavy menstrual bleeding with combined hormonal contraception, use:

1 combined oral contraceptive orally, once daily (see Formulations of combined hormonal contraception available in Australia for formulations). Advise extended or continuous use to avoid or minimise withdrawal bleeding bleeding, heavy menstrual

OR

1 ethinylestradiol+etonogestrel 2.7+11.7 mg ring intravaginally. Advise extended or continuous use to avoid or minimise withdrawal bleeding. Alternatively, if a hormone-free interval is desired, leave ring in place for 3 consecutive weeks then remove; insert new ring after 7 days. bleeding, heavy menstrual ethinylestradiol + etonogestrel ethinylestradiol+etonogestrel ethinylestradiol+etonogestrel

If bleeding has not settled after 6 months of treatment, specialist referral is required to investigate for underlying causes. Also consider indications for earlier referral.