Comment: The quality of evidence is downgraded by imprecise results (few patients).
Comment: The recommendation is strong because potential benefits of the intervention clearly exceed plausible harms.
A Cochrane review «Non‐surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders»1 «Ray S, Ray A. Non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders. Cochrane Database Syst Rev 2016;11():CD010338. »1 included 3 cross-over studies with a total of 175 subjects. In two studies (n = 59) comparing desmopressin with placebo no clear difference between groups was found. The first of these reported a mean difference in menstrual blood loss in the desmopressin vs placebo group of 21.20 mL (95% confidence interval -19.00 to 61.50). In the second study there was no clear evidence of difference in pictorial bleeding assessment chart scores (PBAC). The third study comparing desmopressin with tranexamic acid (n = 116) found a decrease in PBAC after both treatments as compared to baseline. The decrease in these scores was greater for tranexamic acid than for desmopressin, with a mean difference of 41.6 mL (95% CI 19.6 to 63; P < 0.0002). In relation to adverse events, there was no clear difference when placebo was compared to desmopressin, or when desmopressin was compared to tranexamic acid.
Another review «Antifibrinolytics for heavy menstrual bleeding»2 «Cooke I, Lethaby A, Farquhar C. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev 2000;(2):CD000249 [Review content assessed as up-to-date: 5 April 2004]. »2 included 7 trials on antifibrinolytic therapy (tranexamic acid) for heavy menstrual bleeding in women with no known bleeding disorder, of which 4 could be included in the meta-analysis. Antifibrinolytic therapy compared to placebo showed a significant reduction in mean blood loss (WMD -94.0 95% CI -151.4 to -36.5), and significant change in mean reduction of blood loss (WMD -110.2, 95% CI -146.5 to -73.8). Antifibrinolytic therapy compared to other medications (mefenamic acid, norethisterone, or ethamslate), showed a significant reduction in mean blood loss (WMD -73.0, 95% CI -123.4 to -22.6). There were no significant differences in the frequency of reported gastrointestinal side effects with tranexamic acid when compared with either NSAIDs, oral luteal phase progestagens, or ethamsylate. Change in the quality of life measures, flooding and leakage and sex life, were significantly improved in the tranexamic acid group when compared to the oral progestagen group in one trial.
Another Cochrane review «Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta‐analysis»3 «Bofill Rodriguez M, Dias S, Jordan V, et al. Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev 2022;5(5):CD013180 »3 assessed interventions for heavy menstrual bleeding. For first line treatments, meta-analysis included 26 studies with 1770 participants. LNG-IUS resulted in a large reduction of menstrual blood loss (MBL; mean rank 2.4, MD −105.71 mL/cycle, 95% CI −201.10 to −10.33) and was the best option. Antifibrinolytic agents reduced MBL (mean rank 3.7, MD −80.32 mL/cycle, 95% CI −127.67 to −32.98); long‐cycle progestogen reduced MBL (mean rank 4.1, MD −76.93 mL/cycle, 95% CI −153.82 to -0.50), and NSAIDs slightly reduced MBL (mean rank 6.4, MD −40.67 mL/cycle, −84.61 to 3.27). For second line treatments, hysterectomy was the best and endometrial ablation the second best option.