There are a number of different medicines prescribed for menstrual disorders.
Common Pain Relievers for Cramps
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs block prostaglandins, the substances that increase uterine contractions. They are effective painkillers that also help control the inflammatory factors that may be responsible for heavy menstrual bleeding.
Among the most effective NSAIDs for menstrual disorders are ibuprofen (Advil, Motrin, Midol PMS) and naproxen (Aleve), which are both available over-the-counter, and mefenamic acid (Ponstel), which requires a doctor's prescription. Long-term daily use of any NSAID can increase the risk for gastrointestinal bleeding and ulcers, so it is best to just use these drugs for a few days during the menstrual cycle.
Acetaminophen (Tylenol) is a good alternative to NSAIDs, especially for women with stomach problems or ulcers. Some products (Pamprin, Premsyn) combine acetaminophen with other drugs, such as a diuretic, to reduce bloating.
Oral contraceptives (OCs), commonly called birth control pills or "the Pill," contain combinations of an estrogen and a progesterone (in a synthetic form called progestin).
The estrogen compound used in most combination OCs is estradiol. There are many different progestins, but common types include levonorgestrel, drospirenone, and norgestrel. A four-phasic OC that contains estradiol and the progesterone dienogest, has been shown in small trials as effective for treatment of heavy menstrual bleeding.
OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). They also protect against ovarian and endometrial cancers.
Standard OCs usually comes in a 28-pill pack with 21 days of "active" (hormone) pills and 7 days of "inactive" (placebo) pills. Extended-cycle (also called "continuous-use" or "continuous-dosing") oral contraceptives aim to reduce or eliminate monthly menstrual periods. These OCs contain a combination of estradiol and the progestin levonorgestrel, but they use extending dosing of active pills with 81 to 84 days of active pills followed by 7 days of inactive or low-dose pills. Some types of continuous-dosing OCs use only active pills, which are taken 365 days a year.
Common side effects of combination OCs include headache, nausea, bloating, breast tenderness, and bleeding between periods. The estrogen component in combination OCs is usually responsible for these side effects. In general, today's OCs are much safer than OCs of the past because they contain much lower dosages of estrogen.
However, all OCs may increase the risk for migraine, stroke, heart attack, and blood clots. The risk is highest for women who smoke, who are over age 35, or who have a history of heart disease risk factors (such as high blood pressure or diabetes) or past cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for the heart-related complications associated with these pills. Some types of combination OCs contain progestins, such as drospirenone, which have a higher risk for causing blood clots than levonorgestrel.
Progestins (synthetic progesterone) are used by women with irregular or skipped periods to restore regular cycles. They also reduce heavy bleeding and menstrual pain, and may protect against uterine and ovarian cancers. Progestin-only contraceptives may be a good option for women who are not candidates for estrogen-containing OCs, such as smokers over the age of 35.
Progestins can be delivered in various forms.
Short-term treatment of anovulatory bleeding (bleeding caused by lack of ovulation) may involve a 10- to 21-day course of an oral progestin on days 16 to 25 or 5 to 26. Medroxyprogesterone (Provera) is commonly used.
Intrauterine Device (Mirena)
An intrauterine device (IUD) that releases progestin can be very beneficial for menstrual disorders. In the United States, a levonorgestrel-releasing intrauterine system, also called an LNG-IUS, is sold under the brand name Mirena. It is the only IUD approved by the FDA to treat heavy menstrual bleeding.
The LNG-IUS remains in place in the uterus and releases the progestin levonorgestrel for up to 5 years, therefore being considered as a good long-term options.
After the LNG-IUS is inserted, there may be heaver periods initially. However, periods become short eventually with little to no blood flow. For many women, the LNG-IUS completely stops menstrual periods.
Common side effects may include cramping, acne, back pain, breast tenderness, headache, mood changes, and nausea. The LNG-IUS may increase the risk for ovarian cysts, but such cysts usually cause no symptoms and resolve on their own. Women who have a history of pelvic inflammatory disease or who have had a serious pelvic infection should not use the LNG-IUS.
Depo-Provera (also called Depo or DMPA) uses the progestin medroxyprogesterone acetate, which is administered by injection once every 3 months. Most women who use Depo-Provera stop menstruating altogether after a year. Depo-Provera may be beneficial for women with heavy bleeding, or pain due to endometriosis. Women who eventually want to have children should be aware that Depo-Provera can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.
Weight gain can be a problem, particularly in women who are already overweight. Women should not use Depo-Provera if they have a history of liver disease, blood clots, stroke, or cancer of the reproductive organs. Depo-Provera should not be used for longer than 2 years because it can cause loss of bone density.
Gonadotropin releasing hormone (GnRH) agonists are sometimes used to treat severe menorrhagia. GnRH agonists block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen.
GnRH agonists include the implant goserelin (Zoladex), a monthly injection of leuprolide (Lupron Depot), and the nasal spray nafarelin (Synarel). Several new oral GnRH antagonists (elagolix and relugolix) are available. They have similar action of the ovaries as the GnRH agonists. Such drugs may be used alone or in preparation for procedures used to destroy the uterine lining. They are not generally suitable for long-term use.
Commonly reported side effects, which can be severe in some women, include menopausal-like symptoms. These symptoms include hot flashes, night sweats, changes in the vagina, weight change, and depression. The side effects vary in intensity depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped.
The most important concern is possible osteoporosis from estrogen loss. Women should not take these drugs for more than 6 months. Add-back therapy, which provides doses of estrogen and progestin that are high enough to maintain bone density but are too low to offset the beneficial effects of the GnRH agonist, may be used.
GnRH treatments may increase the risk for birth defects. Women who are taking GnRH agonists should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms.
Danazol (Danocrine) is a synthetic substance that resembles a male hormone. It suppresses estrogen, and therefore menstruation, and is occasionally used (sometimes in combination with an oral contraceptive) to help prevent heavy bleeding. It is not suitable for long-term use, and due to its masculinizing side effects it is only used in rare cases. GnRH agonists have largely replaced the use of danazol.
Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and reduced breast size. Danazol may also increase the risk for unhealthy cholesterol levels and it may cause birth defects.
Non-Hormonal Drugs (Lysteda)
Tranexamic acid (Lysteda) is a newer medication for treating heavy menstrual bleeding and the first non-hormonal drug for menorrhagia treatment. Tranexamic acid is given as a pill. It is an anti-fibrinolytic drug that helps blood to clot. The FDA warns that use of this medication by women who take hormonal contraceptives may increase the risk of blood clots, stroke, or heart attacks. This drug should not be taken by women who have a history of venous thromboembolism.