Review: non-steroidal anti-inflammatory drugs reduce menstrual pain and heavy bleeding associated with an intrauterine device
Q In women using an intrauterine contraceptive device (IUD), are non-steroidal anti-inflammatory drugs (NSAIDs) effective for treatment or prevention of heavy menstrual bleeding or pain associated with IUD use?
PubMed, CENTRAL, POPLINE, LILACS, EMBASE/Excerpta Medica, CINAHL, and authors of published trials.
Study selection and assessment:
randomised controlled trials (RCTs) that compared an NSAID with placebo, another NSAID, or another treatment for heavy menstrual bleeding or pain associated with IUD use in reproductive age women of any gravidity and parity. 15 RCTs (8 treatment, n = 370, and 7 prevention, n = 2359) met the selection criteria. Quality assessment of individual trials included randomisation method, allocation concealment, blinding, withdrawals, and follow up.
blood loss (quantitative or semi-quantitative assessment), pain (Likert scales), and IUD discontinuation.
Meta-analysis was not done because of variations in treatments and outcomes. The table summarises the results of individual trials. In treatment trials, NSAIDs reduced menstrual blood loss more than placebo in 3 of 4 trials but did not differ from other treatments in 3 trials. NSAIDs reduced menstrual pain more than placebo in 3 of 4 trials. In prevention trials, NSAIDs reduced menstrual blood loss more than placebo in 2 of 4 trials and reduced menstrual pain more than placebo in 1 of 2 trials. Ibuprofen taken during the first 6 menses did not differ from placebo for IUD discontinuation because of heavy menstrual bleeding or pain.
In women using an intrauterine contraceptive device (IUD), non-steroidal anti-inflammatory drugs (NSAIDs) are effective for treatment of heavy menstrual bleeding and pain, but the evidence for NSAID use to prevent heavy bleeding or pain is inconsistent. No evidence exists that NSAIDs prevent IUD discontinuation.
- Laura Serrant-Green, RGN, PGCE, PhD
The IUD is one of the most commonly used methods of reversible contraception worldwide. However, some women stop using IUDs shortly after insertion, with some of the most frequently cited reasons being pain and heavy bleeding during menses. The systematic review by Grimes et al considered RCTs from 10 countries to investigate the effects of various NSAIDs on reduction of pain and blood loss. The diversity of the populations studied, pharmacological preparations administered, and countries represented make for a stronger review. However, the included trials had some methodological weaknesses, such as insufficient descriptions of randomisation methods, small sample sizes, and high withdrawal rates. Meta-analysis was not feasible because of the use of different measures or units of measurement across trials. In addition, readers should note that women from diverse cultures may perceive or “measure” pain and menstrual blood loss differently. For practitioners, the major strength of the review is in the compilation of clear evidence to support the use of NSAIDs for women with IUDs who experience pain or unacceptable blood loss during menses. The consistency of positive effects with various types of NSAIDs on these outcomes underpins the authors’ decision not to recommend further research to determine the relative effectiveness of different NSAIDs.
The findings are relevant to family planning and sexual health nurses, and those working in gynaecological units and community based nurse led or outreach clinics. The results provide evidence for the management of women using IUDs who are experiencing associated pain and heavy blood loss during menses.
For correspondence: Dr D Grimes, Family Health International, Durham, NC, USA.
Sources of funding: US Agency for International Development and National Institute of Child Health and Human Development.