The use of hormonal contraceptives in fertility treatments: a committee opinion.

The use of hormonal contraception can be considered to aid in the timing of assisted reproductive technology cycles, reduce the risk of ovarian cysts at in vitro fertilization cycle initiation, and optimize visualization before hysteroscopy.

Effect of the Covid pandemic on progestogen-only and oestrogen-containing contraceptive prescribing in general practice: a retrospective analysis of English prescribing data.

OBJECTIVES: This paper looks at how trends in contraceptive prescribing by General Practices in England were affected by the Covid pandemic and lockdown. It compares English prescribing data from May 2014 to May 2021, including the period of 'lockdown', from April 20-June 20. DESIGN & SETTING: A retrospective analysis of the English Prescribing Dataset which reports monthly on prescribed items from English General Practices was carried out. Data on all forms of prescribed contraceptive methods were extracted using British National Formulary (BNF) codes, and total quantities tabulated by method, then transformed into 'months of contraception provided' by each method. RESULTS: Prescription of the combined oral contraceptive pill reduced by 22% during the period of lockdown compared to the same three months in 2019. Prescriptions of Progestogen-Only pills remained stable. This continued a trend in oral contraceptive prescribing evident from May14. Prescription of long-acting methods reduced during the period of lockdown, with the greatest reductions in implants (76% reduction from pre-lockdown levels), intra-uterine systems (79% reduction from pre-lockdown levels) and intrauterine devices (76% reduction from pre-lockdown levels). These rates of contraceptive provision recovered quickly after the period of lockdown ended. CONCLUSIONS: The disruption of face-to-face contraceptive consultations in General Practice during a Covid-19 'lockdown' has resulted in a reduction in oestrogen -containing methods compared to progestogen-only methods, which require less face-to-face monitoring. Implant and intrauterine contraceptive device prescription reduced by three quarters over the first three months of lockdown, but rebounded in the next year.

Dysmenorrhea.

Dysmenorrhea is common and usually independent of, rather than secondary to, pelvic pathology. Dysmenorrhea occurs in 50% to 90% of adolescent girls and women of reproductive age and is a leading cause of absenteeism. Secondary dysmenorrhea as a result of endometriosis, pelvic anatomic abnormalities, or infection may present with progressive worsening of pain, abnormal uterine bleeding, vaginal discharge, or dyspareunia. Initial workup should include a menstrual history and pregnancy test for patients who are sexually active. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives are first-line medical options that may be used independently or in combination. Because most progestin or estrogen-progestin combinations are effective, secondary indications, such as contraception, should be considered. Good evidence supports the effectiveness of some nonpharmacologic options, including exercise, transcutaneous electrical nerve stimulation, heat therapy, and self-acupressure. If secondary dysmenorrhea is suspected, nonsteroidal anti-inflammatory drugs or hormonal therapies may be effective, but further workup should include pelvic examination and ultrasonography. Referral to an obstetrician-gynecologist may be warranted for further evaluation and treatment.

Surgical treatment and fertility perservation in endometrial cancer.

BACKGROUND: Endometrial cancer (EC) represents a high health burden in Slovenia and worldwide. The incidence is increasing due to lifestyle and behavioural risk factors such as obesity, smoking, oestrogen exposure and aging of the population. In many cases, endometrial cancer is diagnosed at an early stage due to obvious signs and symptoms. The standard treatment is surgery with or without adjuvant therapy, depending on the stage of the disease and the risk of recurrence. However, treatment modalities have changed in the last decades, considerably in the extent of lymphadenectomy. CONCLUSIONS: The gold standard of treatment for is surgery, which may be the only treatment modality in the early stages of low-grade tumours. In recent years, a minimally invasive approach with sentinel node biopsy (SNB) has been proposed. A conservative approach with hormonal treatment is used if fertility preservation is desired. If EC is in advance stage, high-risk histology, or high grade, radiotherapy, chemotherapy, or a combination of both is recommended.

Plastic Surgical Management of Hidradenitis Suppurativa.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the pathogenesis of hidradenitis suppurativa. 2. Discuss perioperative multimodal therapy of hidradenitis suppurativa, including medical optimization. 3. Determine an appropriate surgical plan with excision and reconstruction based on hidradenitis suppurativa severity, size, and anatomical location. SUMMARY: Successful treatment of hidradenitis suppurativa requires a multidisciplinary team approach and multimodal therapy.

Letrozole combined with oral contraceptives versus oral contraceptives alone in the treatment of endometriosis-related pain symptoms: a pilot study.

BACKGROUND: To compare the efficacy and the tolerability of letrozole combined with oral contraceptives versus oral contraceptives alone in treating endometriosis-related pain. METHODS: A total of 820 women with endometriosis presented with endometriosis-related pain were enrolled with this study. Patients were randomly treated either with letrozole (2.5 mg/day) combined with oral contraceptives (Desogestrel and Ethinylestradiol Tablets) or oral contraceptives (Desogestrel and Ethinylestradiol Tablets) alone for 6 months. Changes in pain symptoms during treatment and in 1 months after treatment, 6-month follow-up and 12-month follow-up were evaluated. Adverse effects of each treatment protocol were recorded. RESULTS: At completion of treatment, the intensity of chronic pelvic pain continued to decrease during treatment and at 1-month after treatment it was significantly lower than at 6-month follow-up and baseline level both in LE + oral contraceptives group (Mean ± SD,1.5 ± 1.4) and in oral contraceptives alone group(Mean ± SD,2.9 ± 1.2).The intensity of chronic pelvic pain and deep dyspareunia was significantly decrease at both 1-month after treatment and 6-month follow-up. CONCLUSIONS: This treatment for endometriosis is a promising new modality that warrants further investigation.

Assessment of the adequacy of counselling regarding reproductive-related issues in women of childbearing age on anti-epileptic drugs.

BACKGROUND: The use of anti-epileptic drugs (AEDs) in women of childbearing age (WCBA) necessitates careful counselling regarding reproductive-related issues. AIM: (i) To compare documentation of appropriate counselling regarding reproductive-related issues in WCBA prescribed AEDs for non-epilepsy vs. epilepsy indications, and (ii) to examine whether the frequency of counselling improved after introduction of 'standardized typed advice'. DESIGN: Retrospective audit and quality assessment and improvement programme. METHODS: We analysed medical records of all WCBA prescribed gabapentin, pregabalin, topiramate, valproate or carbamazepine by a general neurology clinical service before (Study period A) and after (Study period B) introduction of standardized typed passages regarding potential teratogenicity ± interactions with hormonal contraception at a university teaching hospital. The χ2 test or the Fisher's exact test was employed, as appropriate. RESULTS: In WCBA prescribed AEDs for non-epilepsy indications, documentation of appropriate counselling regarding potential teratogenicity improved from 49% (17/35 patients) in Period A to 79% (27/34 patients) in Period B (P = 0.008). The frequency of counselling regarding teratogenicity was higher in patients prescribed AEDs for epilepsy compared with non-epilepsy indications in Study period A (100% vs. 49%, P = 0.002), but was no longer significantly different in Study period B (86% vs. 79%, P = 0.64). Documentation of counselling regarding potential interaction of enzyme-inducing AEDs with hormonal contraception did not significantly change between study periods. CONCLUSION: Significant improvements in documentation regarding potential teratogenicity of AEDs prescribed for non-epilepsy indications can be achieved by introducing standardized, typed passages copied to patients. Such a practice change is practical and widely applicable to neurological and non-neurological practice worldwide.

Bilateral Boston keratoprosthesis type 1 in a case of severe Mooren's ulcer.

INTRODUCTION: Mooren's ulcer is a painful, inflammatory chronic keratitis that affects corneal periphery, progressing centripetally, ultimately ending in perforation. The first line of treatment includes systemic immunomodulators, with surgery being the last option. We present a case of bilateral Boston keratoprosthesis implantation for severe Mooren's ulcer that responded differently in each eye. CLINICAL CASE: A 32-year-old male with corneal opacification, anterior staphylomas, vision of hand movement, was started on systemic immunosuppression with cyclosporine. After two failed penetrating keratoplasties in each eye, high intraocular pressure despite diode cyclophotocoagulation, and cystic macular edema, we performed Boston keratoprosthesis type 1 in both eyes. The right eye responded initially well, with a best-corrected visual acuity of 20/80 and normal intraocular pressure. The left eye presented high intraocular pressure, which required cyclophotocoagulation, ultimately resulting in hypotony. Boston keratoprosthesis was performed but had peripheral corneal necrosis that progressed despite amniotic membrane transplantation and aggressive intensive treatment with medroxyprogesterone, autologous platelet-rich-in-growth-factors eye drops, and oral doxycycline. Thus, replacement of the semi-exposed Boston keratoprosthesis with tectonic penetrating keratoplasty was necessary. However, both eyes developed phthisis bulbi with final visual acuity of perception of light with poor localization. CONCLUSION: Mainstay treatment of Mooren's ulcer is systemic immunomodulation. Surgical treatment must be considered only when risk of perforation, preferably with inflammation under control. Penetrating keratoplasty frequently fails, and Boston keratoprosthesis may be a viable option. However, postoperative complications, especially uncontrolled high intraocular pressure, corneal necrosis, and recurrence of Mooren's ulcer may jeopardize the outcomes and need to be addressed promptly with intensive topical and systemic treatment.

Medical therapy options for endometriosis related pain, which is better? A systematic review and network meta-analysis of randomized controlled trials.

Our objective was to assess and rank different pharmacological interventions for relieving endometriosis-related pain. We conducted an online bibliographic search in different databases from their inception until March 2019. We included randomized controlled trials (RCTs) that assessed different medical therapies in the management of endometriosis-related pain. We applied this network meta-analysis (NMA) based on the frequentist approach using statistical package "netmeta" (version 1.0-1) in R software. Our main outcomes were the change in severity of pelvic pain, dysmenorrhea score, non-menstrual pelvic pain score, and dyspareunia score. Overall, 36 RCTs were included in this study (patients no. = 7942). Dienogest (0.94), combined hormonal contraceptives (CHCs) (0.782), and elagolix (0.38) were the highest-ranked interventions for reducing the severity of pelvic pain at three months, while at six months, gonadotropin-releasing hormone (GnRH) analogues (0.75), levonorgestrel-releasing intrauterine system (LNG-IUS) (0.73), and dienogest (0.65) were linked to more reduction in pelvic pain. The ranking p-score showed that GnRH analogues was the highest-ranked treatment for reducing dysmenorrhea at 3 months (1.00), while CHCs were the highest-ranked treatment at 6 months (0.97), followed by GnRH analogues (0.89). GnRH analogues (0.63) and elagolix (0.54) at three months while desogestrel (0.94) and CHCs (0.91) at six months were the highest-ranked treatment to reduce non-menstrual pelvic pain. GnRH analogues and elagolix were the highest-ranked pharmacologic therapies for reducing dyspareunia. In conclusion, CHCs, GnRH analogues, progesterone, and elagolix were the best approaches in reducing the pain of endometriosis.

Association of Retinal Vascular Occlusion With Women Filling a Prescription for Female Hormone Therapy.

Importance: Oral contraceptives have been associated with cardiovascular disease, ischemic stroke, venous thromboembolic disease, and breast cancer. Retinal vascular occlusions share the same risk factors as cardiovascular and cerebrovascular disease. Objective: To determine whether filling a prescription of female hormone therapy (FHT) is associated with an increased risk of retinal artery occlusion (RAO) or retinal vein occlusions (RVO). Design, Setting, and Participants: A multiple-cohort study was conducted using an administrative claims insurance database comparing women who filled a prescription for FHT with matched control individuals. Exclusion occurred for those enrolled for less than 2 years in the plan, with no prior ophthalmologic examination, with a history of a RAO/RVO, with systemic diseases/medications that affected estrogen levels, or a disease associated with an increased risk for thromboembolism. Main Outcomes and Measures: The primary outcome was the incidence of a new diagnosis of RAO or RVO. Cox proportional hazard regression modeling with inverse probability of treatment weight was used to assess the hazard ratio (HR) for a new diagnosis of RAO or RVO relative to filling prescription for FHT. Subanalyses were conducted to stratify by age, race/ethnicity, diabetes, and hypertension. Results: A total of 205 304 women who filled a prescription for FHT were matched to 755 462 control individuals. After inverse probability of treatment weight, the study cohort was a mean age of 47.2 years, 71% were White, 7% were Black, 6% were Hispanic, 3% were Asian, and 3% were unknown. There were 41 cases (0.01%) of RAO and 68 cases of RVO (0.02%) in the FHT cohort. In comparison, there were 373 cases of RAO (0.05%) and 617 cases of RVO (0.08%) in the control cohort. After inverse probability of treatment weight, Cox regression analysis showed no difference in hazard for RAO, RVO, or combined outcomes in the FHT cohort relative to the control cohort (RAO HR, 1.17; 95% CI, 0.83-1.65; P = .36; RVO HR, 1.07; 95% CI, 0.82-1.39; P = .65; combined HR, 1.10; 95% CI, 0.89-1.36; P = .37). Subanalyses that stratified by age, diabetes, and hypertension similarly showed no significant associations between the FHT prescription cohort and all outcomes. Conclusions and Relevance: These findings suggest that filling a prescription for FHT, and presumably taking FHT, does not increase the risk of RAO or RVO. Such history may not be relevant in the evaluation of an individual with an RAO or RVO nor do our results support stopping FHT in an individual who develops an RAO or RVO.

Primary Dysmenorrhea: Diagnosis and Therapy.

Primary dysmenorrhea is defined as pain during the menstrual cycle in the absence of an identifiable cause. It is one of the most common causes of pelvic pain in women. Dysmenorrhea can negatively affect a woman's quality of life and interfere with daily activities. The pathophysiology of primary dysmenorrhea is likely a result of the cyclooxygenase pathway producing increased prostanoids, particularly prostaglandins (PGs). The increased PGs cause uterine contractions that restrict blood flow and lead to the production of anaerobic metabolites that stimulate pain receptors. Women with a history typical for primary dysmenorrhea can initiate empiric treatment without additional testing. Shared decision making is key to effective management of dysmenorrhea to maximize patient compliance and satisfaction. After a discussion of their risks and benefits, extremely effective empiric therapies are nonsteroidal antiinflammatory drugs and contraceptive hormonal therapy. Other treatments for primary dysmenorrhea can be employed solely or in combination with other modalities, but the literature supporting their use is not as convincing. The physician should initiate an evaluation for secondary dysmenorrhea if the patient does not report improved symptomatology after being compliant with their medical regimen.

A progestin isn't a progestin: dienogest for endometriosis as a blueprint for future research - Review as a contribution for discussion.

The different etiopathogenetic mechanisms and the diversity of clinical features of endometriosis has not yet allowed to identify a causal pharmacological monotherapy satisfying the unresolved medical needs in this important female disease. Therefore, despite the search for new therapeutic principles for the indication, the strategy of gradual optimization of established therapeutic principles should not be disregarded.In the case of progestins, the fact that each compound has its own, specific profile may allow to study the therapeutic relevance of the various signal cascades influenced by their receptors.Using the example of the progestin dienogest, the different genomic and non-genomic mechanisms of action are discussed. It is pharmacodynamic profile is unique compared to other progestins.In light of the emerging multitude of pathomechanisms in endometriosis, a monotherapy may not be possible, and then the search for broad spectrum compounds or combination therapies with dual or multiple mode of action in a clinically relevant dose range might be considered. The progestogenic action may greatly benefit from, by way of example, additional anti-inflammatory and/or anti-fibrotic and/or pro-apoptotic activities. Such a strategy could lead to new drug classes.

Comparison of effect of preoperative dienogest and gonadotropin-releasing hormone agonist administration on laparoscopic cystectomy for ovarian endometriomas.

PURPOSE: To compare the effects of preoperative dienogest (DNG) and gonadotropin-releasing hormone (GnRH) agonist administration on the improvement of preoperative symptoms and surgical outcomes in patients who underwent laparoscopic cystectomy for ovarian endometriomas. METHODS: Seventy patients who were scheduled for laparoscopic surgery were enrolled in the study. They were divided into two groups: 35 patients who received DNG for 4 months preoperatively (group D) and 35 patients who received low-dose sustained-release goserelin acetate for 4 months preoperatively (group G). Preoperative outcomes, including pain score associated with endometriosis, using the numerical rating scale (NRS), adverse events of hormonal therapy and Kupperman index (KI) before and after treatment, surgical outcomes including total surgical duration and blood loss, and postoperative recurrence of endometrioma were compared between the two groups. RESULTS: Regarding preoperative symptoms, NRS and KI at 4 months after preoperative hormonal therapy were significantly lower in group D than in group G (NRS, 5.3 ± 5.5 vs. 2.7 ± 3.9; P = 0.01; KI, 16.0 ± 11.0 vs. 9.2 ± 7.6; P = 0.006). Regarding adverse events, the incidence of hot flashes was significantly lower in group D than in group G (P < 0.001). Meanwhile, the incidence of breast pain and metrorrhagia was significantly higher in group D than in group G (P = 0.04 and P < 0.001, respectively). The total surgical duration and blood loss were not significantly different between the groups. At 12 months after surgery, ovarian endometrioma did not recur in either group. CONCLUSION: Preoperative administration of DNG is more valuable for patients with endometriosis and scheduled for laparoscopic surgery to improve symptoms with good efficacy and tolerability than the administration of GnRH agonist.

Pharmacist prescription and access to hormonal contraception for Medicaid-insured women in Oregon.

OBJECTIVE: To assess the impact of Oregon's policy that allows pharmacist prescription of the pill and patch on contraceptive receipt for Medicaid-insured women. STUDY DESIGN: We conducted a difference-in-differences analysis using Oregon Medicaid claims data to compare changes in receipt of all contraceptive services and receipt of the pill or patch for Medicaid-enrolled women (n = 436,258) before and after policy implementation in areas with and without participating pharmacists. We then described filled prescriptions for the contraceptive pill and patch by type of prescribing provider before and after implementation of the policy. We also compared past contraceptive use for women receiving prescriptions from pharmacists and non-pharmacists. RESULTS: We found no significant policy effects on receipt of all contraceptive services or on receipt of the pill or patch. More than 98% of prescriptions filled for the pill and patch in the first two years of policy implementation were prescribed by a non-pharmacist provider. Women receiving contraceptive pill and patch prescriptions from pharmacists and non-pharmacists were equally likely to be continuing contraceptive users. CONCLUSION: We identified no increase in receipt of contraceptive services among Medicaid-insured women in the two years following the implementation of a pharmacy access policy. Additional research is needed to investigate other possible benefits of the policy, such as satisfaction, convenience, cost and equity. IMPLICATIONS: We identified no effect of allowing pharmacist prescription of the contraceptive pill and patch on increasing utilization of contraceptive services for Medicaid-insured women in Oregon. Impacts on access to contraceptive services and unintended pregnancy may emerge in subsequent years as availability of and demand for pharmacist-prescribed hormonal contraception increases.

Outpatient Management of Heavy Menstrual Bleeding in Adolescent and Young Women with Inherited Platelet Function Disorders.

STUDY OBJECTIVE: To assess the treatment patterns and efficacy of hormonal (HM) and non-HM (NHM) management of heavy menstrual bleeding (HMB) in young women with inherited platelet function disorders (IPFDs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective chart review was performed of outpatient treatment of HMB in female patients age 9-25 years who were diagnosed with IPFDs and referred to gynecology and/or hematology at a tertiary care hospital between 2006 and 2018. INTERVENTIONS: The study sample was identified using billing codes for IPFDs. Data on HM and NHM treatments and outcomes over a one- to two-year period were collected. Initial treatment was defined as the first treatment prescribed after referral. Descriptive statistics, Pearson χ2, and t tests were used for analysis. MAIN OUTCOME MEASURES: Treatment failure was defined as a change in treatment method because of continued bleeding. RESULTS: Thirty-four girls met inclusion criteria. After their initial visit, 19/34 (56%) were treated with HM, 12/34 (35%) with NHM, 2/34 (6%) with a combination of methods, and 1/34 (3%) were untreated. Initial treatment failed in 19/34 (56%) and those patients subsequently required a mean of 2 additional treatments during follow-up. Of the 34 included, 6/34 (18%) remained uncontrolled despite numerous treatment changes and 2/34 (6%) because of noncompliance. When control was achieved, 7/26 (27%) of patients were receiving combined oral contraceptives and 6/26 (23%) desmopressin acetate. CONCLUSION: HMB in girls with IPFDs can be difficult to control despite ongoing follow-up and treatment changes. Although the most effective treatment for HMB in young women with IPFDs was not identified, these findings will help providers and patients with setting expectations. Prospective studies are needed to develop recommendations on best practices.

Interventions commonly available during pandemics for heavy menstrual bleeding: an overview of Cochrane Reviews.

BACKGROUND: Within the context of heavy menstrual bleeding, pandemics impact upon women's assessment and treatment by healthcare providers. OBJECTIVES: To summarise the evidence from Cochrane Reviews evaluating interventions for heavy menstrual bleeding that are commonly available during pandemics. METHODS: We sought published Cochrane Reviews, evaluating interventions that can continue during pandemics for women with heavy menstrual bleeding with no known underlying cause. We identified Cochrane Reviews by searching the Cochrane Database of Systematic Reviews in June 2020. The primary outcome was menstrual bleeding. Secondary outcomes included quality of life, patient satisfaction, side effects, and serious adverse events. We undertook the selection of systematic reviews, data extraction, and quality assessment in duplicate. We resolved any disagreements by discussion. We assessed review quality using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) 2 tool, and the certainty of the evidence for each outcome using GRADE methods. MAIN RESULTS: We included four Cochrane Reviews, with 11 comparisons, data from 44 randomised controlled trials (RCTs), and 3196 women. We assessed all the reviews to be high quality. Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs may be more effective in reducing heavy menstrual bleeding than placebo (mean difference (MD) -124 mL per cycle, 95% confidence interval (CI) -186 to -62 mL per cycle; 1 RCT, 11 women; low-certainty evidence). Mefenamic acid may be similar to naproxen (MD 21 mL per cycle, 95% CI -6 to 48 mL per cycle; 2 RCTs, 61 women; low-certainty evidence), and NSAIDs may be similar to combined hormonal contraceptives for heavy menstrual bleeding (MD 25 mL per cycle, 95% CI -22 to 73 mL per cycle; 1 RCT, 26 women; low-certainty evidence). NSAIDs may be be less effective in reducing menstrual bleeding than antifibrinolytics (relative risk (RR) 0.70, 95% CI 0.58 to 0.85; 2 RCTs, 161 women; low-certainty evidence). We are uncertain whether NSAIDs reduce menstrual blood loss more than short-cycle progestogens (RR 0.80, 95% CI 0.49 to 1.32; 1 RCT 32 women; very low-certainty evidence). Antifibrinolytics Antifibrinolytics appear to be more effective in reducing heavy menstrual bleeding than placebo (MD -53 mL per cycle, 95% CI -63 to -44 mL per cycle; 4 RCTs, 565 women; moderate-certainty evidence). Antifibrinolytics may be similar to placebo on the incidence of side effects (RR 1.05, 95% CI 0.93 to 1.18; 1 RCT, 297 women; low-certainty evidence), and they are probably similar on the incidence of serious adverse events (thrombotic events; RR 0.10, 95% CI 0.00 to 2.46; 2 RCT, 468 women; moderate-certainty evidence). Antifibrinolytics may be more effective in reducing heavy menstrual bleeding than short-cycle progestogen (MD -111 mL per cycle, 95% CI -178 mL to -44 mL per cycle; 1 RCT, 46 women; low-certainty evidence). We are uncertain whether antifibrinolytics are similar to short-cycle progestogens on quality of life (RR 1.67, 95% CI 0.76 to 3.64; 1 RCT, 44 women; very low-certainty evidence), patient satisfaction (RR 0.91, 95% CI 0.59 to 1.39; 1 RCT, 42 women; very low-certainty evidence), or side effects (RR 0.85, 95% CI 0.65 to 1.12; 3 RCTs, 211 women; very low-certainty evidence). We are uncertain whether antifibrinolytics are more effective in reducing heavy menstrual bleeding when compared with long-cycle progestogen (MD -9 points per cycle, 95% CI -30 to 12 points per cycle; 2 RCTs, 184 women; low-certainty evidence). Antifibrinolytics may increase self-reported improvement in menstrual bleeding when compared with long-cycle medroxyprogesterone acetate (RR 1.32, 95% CI 1.08 to 1.61; 1 RCT, 94 women; low-certainty evidence). Antifibrinolytics may be similar to long-cycle progestogens on quality of life (MD 5, 95% CI -2.49 to 12.49; 1 RCT, 90 women; low-certainty evidence). We are uncertain whether antifibrinolytics are similar to long-cycle progestogens on side effects (RR 0.58, 95% CI 0.33 to 1.00; 2 RCTs, 184 women; very low-certainty evidence). There were no trials comparing antifibrinolytics to combined hormonal contraceptives. Combined hormonal contraceptives Combined hormonal contraceptives appear to be more effective for heavy menstrual bleeding than placebo or no treatment (RR 13.25, 95% CI 2.94 to 59.64; 2 RCTs, 363 women; moderate-certainty evidence). Combined hormonal contraceptives are probably similar to placebo on the incidence of side effects (RR 1.53, 95% CI 0.90 to 2.60; 2 RCTs, 411 women; moderate-certainty evidence). Progestogens There were no trials comparing progestogens to placebo. Limitations in the evidence included risk of bias in the primary RCTs, inconsistency between the primary RCTs, and imprecision in effect estimates. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that antifibrinolytics and combined hormonal contraceptives reduce heavy menstrual bleeding compared with placebo. There is low-certainty evidence that NSAIDs reduce heavy menstrual bleeding compared with placebo. There is low-certainty evidence that antifibrinolytics are more effective in reducing heavy menstrual bleeding when compared with NSAIDs and short-cycle progestogens, but we are unable to draw conclusions about the effects of antifibrinolytics compared to long-cycle progestogens, on low-certainty evidence.