Use of NSAIDs in abnormal uterine bleeding

NSAIDs can be used as an effective first line treatment in abnormal uterine bleeding in women with no obvious pathological conditions (1)

• these act by inhibiting prostaglandin synthesis
• may also alter favorably the ratio between thromboxne A2 (a vasoconstrictor and promoter of platelet aggregation) and prostocyclin (a vasodilator and platelet inhibitor) (1)

Out of the five main groups of NSAIDs, fenamates (e.g. - mefenemic acid) have been studied extensively on abnormal uterine bleeding (2)

• in addition to prostoglanding inhibition fenamates are also thought to improve endometrial haemostasis
• reduction in menstrual blood flow may vary between 20% to 50%
• long term effectiveness of treatment has been shown to be good (2)

Other NSAIDs naproxen, ibuprofen, sodium diclofenac, and flurbiprofen can be used as well. Depending on the agent and the dosage used, the reduction in blood loss varies between 25% and 47% (2).

NSAIDs are usually started on the first day of menstruation (or just before) and continued for 5 days or until cessation of bleeding. Hence it is suitable for women who are trying to conceive (2,3).

NSAIDs are effective in reducing blood loss associated with copper or non hormonal IUD

• patients who started mefenemic acid (500mg three times a day) form the first day of bleeding, a reduction of bleeding by
  • 34% is seen in IUD users with a pretreatment MBL >80 ml o 23% in women with a pretreatment MBL <80 ml (2)

Although other agents are superior with respect of decreasing blood loss, NSAIDs are used due to their low profile of adverse effects and the additional benefit of alleviating menstrual pain (2).

With respect to NSAIDs and/or tranexamic acid ongoing use of NSAIDs and/or tranexamic acid is recommended for as long as it is found to be beneficial by the woman if there is no improvement in symptoms within 3 menstrual cycles then use of NSAIDs and/or tranexamic acid should be stopped (3).

Reference:

• 1. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008;35(2):219-34
• 2. Peter Joseph O'Donovan, Charles E Miller. Modern Management of Abnormal Uterine Bleeding (2008)
• 3. National Institute for Health and Clinical Excellence (NICE) 2016. Heavy menstrual bleeding.