[Downloaded free from http://www.cjhr.org on Thursday, June 13, 2019, IP: 114.125.76.

19]

Original Article

A Comparative Study of Norethisterone and Combined Oral Contraceptive

Pill in the Treatment of Dysfunctional Uterine Bleeding

Abstract Sayantan Sen,

Background: A  significant percentage of women in India suffer from dysfunctional uterine Tapan Kumar
bleeding (DUB), which has a negative impact on physical and social life. Norethisterone and low‑dose Mandal,
combined oral contraceptive  (COC) pills are used in the treatment of DUB. Aim: The aim of this
study was to compare the efficacy and safety of norethisterone and low‑dose COC pills in reduction Arijit Dutta,
of blood loss in DUB. Materials and Methods: A prospective randomized interventional study was Himel Mondal1,
conducted with patients with DUB. Pretreatment pictorial blood loss assessment chart  (PBAC) and Tufan Khalua
hemoglobin in blood were obtained from patients. Then, Group  I  (n  =  50) and Group  II  (n  =  50) Department of Gynecology and
patients were provided treatment with norethisterone and low‑dose COC pills, respectively. Obstetrics, Burdwan Medical
Posttreatment PBAC and hemoglobin level in blood was obtained after 6  months of treatment. College and Hospital, Burdwan,
Improvements in PBAC and hemoglobin level  (difference between posttest and pretest value) were West Bengal, 1Department
compared by unpaired t‑test with α = 0.05. Results: Mean age of Group I and Group II patients was of Physiology, Fakir Mohan
Medical College and Hospital,
28.62  ±  9.84 and 28.42  ±  10.08  years, respectively. Improvement in PBAC score in patients treated
Balasore, Odisha, India
with norethisterone versus low‑dose COC pill was  −98.62  ±  7.82 versus  −96.44  ±  8.74  (P  =  0.19).
Improvement in hemoglobin level in patients treated with norethisterone versus low‑dose COC
pill was 2.75  ±  1.06  gm/dL versus 2.71  ±  0.86  gm/dL  (P  =  0.84). Conclusion: Norethisterone and
low‑dose COC pills were found to be equally efficacious in reducing bleeding in DUB. Hence,
any one of the drugs can be used in the treatment of DUB according to patients’ profile. However,
considering the side effects, low‑dose COC pills may be a better choice.

Keywords: Abnormal uterine bleeding, hemoglobins, menorrhagia, menstruation disturbances,

uterine hemorrhage

Introduction this semi‑subjective method is a better

Dysfunctional uterine bleeding  (DUB) is
excessive uterine bleeding which is not
attributed to pregnancy or any detectable
uterine or systemic pathology.[1,2] Patients
suffering from DUB commonly complain
about heavy menstrual bleeding  (HMB),
irregular bleeding, spotting between
periods, or spotting after sex.[3,4] About
17.9% of Indian women suffer from
method than the subjective method of
assessment.[10,11]
There are several treatment strategies
for DUB according to the cause of the
disorder.[12] With an aim to reduce the
amount of bleeding and prevent its
recurrence, the medical management Submission: 20-Jun-18
includes the use of  antifibrinolytic Revised : 12-Jul-18
drug – tranexamic acid, inhibitor of Accepted : 15-Aug-18

DUB.[5] prostaglandin synthesis – nonsteroidal

anti‑inflammatory drugs, combined oral Address for correspondence:
Diagnosis of DUB depends on detailed
contraception pill, progestogen, danazol, Dr. Himel Mondal,
history, clinical examination, estimation
and gonadotropin‑releasing hormone Department of Physiology, Fakir
of blood loss in menstruation along Mohan Medical College and
analogs.[13‑15]
with complete blood count  (CBC), Hospital, Balasore - 756 019,
ultrasonography and wherever possible Several previous studies have Odisha, India.
E‑mail: himelmkcg@gmail.com
hysteroscopy, biopsy, and magnetic evaluated the efficacy of combined oral
resonance imaging.[6,7] Pictorial blood loss contraceptive  (COC) pill and ormeloxifene
assessment chart  (PBAC) is an easy way in the treatment of DUB, and both of Access this article online
to estimate blood loss during menstruation them were found effective in reduction
Website: www.cjhr.org
by scoring the blood‑stained sanitary of menstrual bleeding.[16‑18] Studies
napkin/towel/pad.[8] Despite criticism,[9] also reported the comparison between DOI: 10.4103/cjhr.cjhr_92_18

ormeloxifene and norethisterone in the Quick Response Code:

This is an open access journal, and articles are distributed under
the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate
credit is given and the new creations are licensed under the
identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Sen S, Mandal TK,
Dutta A, Mondal H, Khalua T. A comparative study
of norethisterone and combined oral contraceptive
pill in the treatment of dysfunctional uterine bleeding.
CHRISMED J Health Res 2019;6:87-92.

© 2019 CHRISMED Journal of Health and Research | Published by Wolters Kluwer - Medknow 87
[Downloaded free from http://www.cjhr.org on Thursday, June 13, 2019, IP: 114.125.76.19]
Sen, et al.: Norethisterone and OCP in dysfunctional uterine bleeding
treatment of DUB and found ormeloxifene to be superior
in the management of DUB.[19,20] A study by Patel et  al.
evaluated the comparative efficacy of COC pill and
norethisterone in puberty menorrhagia and reported that
norethisterone was more effective than COC pills.[21] The
study participants were confined to a limited age group
and authors used only hemoglobin and menorrhagia impact
questionnaire to evaluate the efficacy. Furthermore, a
study by Chauhan et  al. evaluated the comparison among
norethisterone, ormeloxifene, and COC and reported
ormeloxifene to be better than norethisterone and COC.
In that study, the authors used hemoglobin and subjective
score for assessment of improvement in the status of
bleeding.[22]
With this background, the current study was aimed to
evaluate the efficacy and safety of norethisterone and COC
pills in the reduction of blood loss in patients presenting
with DUB. The study was further aimed to recruit patients
with wider range of age to get a credible result applied to
general population and to use both PBAC and hemoglobin
for the evaluation of amount of blood loss.
Materials and Methods
After obtaining clearance from Clinical Research Ethics
Committee, Burdwan Medical College and Hospital
(BMC/PG/59), this prospective randomized interventional
study was conducted in the Department of Gynecology
and Obstetrics, Burdwan Medical College and Hospital,
Bardhaman, West Bengal, India, from March 2016 to
February 2017.
Minimum sample size estimation
After reviewing related literature, the expected pretreatment
and posttreatment PBAC score was considered as 300 and
200, respectively. With an assumption of standard deviation
of 100, the minimum sample size was calculated with the
formula:[23] N = [(1/q1 + 1/q2) S2 (Zα + Zβ) 2] ÷ E2.
Where N is the total number of patients required, q1 and
q2 are the proportion of patients in each group, S is the
expected standard deviation, Zα and Zβ are standard
normal deviate of α and β, respectively, and E is the
effect size  (difference between mean of two groups). With
α = 0.05 and power of the study as 95%, the estimated
sample size was 52. Twenty percent was added to this
minimum number which provided a minimum sample size
of 62. This sample size was considered minimum for a
statistically significant study. In this study, it was aimed to
include a total of 50 patients in each group.
Ethical consideration
This study was conducted with full compliance to the
declaration of Helsinki 2013.[24] The informed consent for
participation in the study was obtained from the patients
whose age was above 18  years  (considered adult in India).
Where age of the patients was  <18  years, consent was
88 CHRISMED Journal of Health and Research | Volume 6 | Issue 2 | April-June 2019
obtained both from the patient and their legal guardian.
The aim and procedure of the study were described to the
patients in detail. Furthermore, the patients were informed
that they can discontinue the treatment at any point of
time and have full choice not to continue with the study
follow‑up without stating any reason.
Recruitment of subjects
Patients were recruited from the Outpatient Department
of Obstetrics and Gynecology, Burdwan Medical
College and Hospital, Bardhaman, West Bengal, India.
Patients complaining of HMB were further evaluated
for a diagnosis of DUB. Patients who were pregnant and
those who presented with severe bleeding which require
emergency treatment were not included in the study.
A detailed medical and surgical history with history of drug
intake was obtained for the presence of any abnormality
other than DUB. Clinical general examination and per
speculum examination were conducted to exclude any
disease or deformity. Then, CBC was carried out to
exclude any blood disorder. Thyroid‑stimulating hormone
was tested for the exclusion of hypo‑  or hyperthyroidism.
Pelvic ultrasonography and Pap smear were examined to
further exclusion of any disease. Patients with no detected
abnormality other than DUB were then included in the
study. The protocol of patient recruitment is shown in
Figure 1.
Pictorial blood loss assessment chart score and
hemoglobin estimation
The original PBAC scorecard includes assessment
for stained tampon. According to the availability and
convenience, in this study, only sanitary pad was used.
Hence, a modified PBAC scorecard was made for this
study with score for pads and clots. In addition, due to
the convenience of Bengali speaking patients, the PBAC
card was made in the Bengali language. The scorecard
Figure 1: Patient recruitment procedure for the study
[Downloaded free from http://www.cjhr.org on Thursday, June 13, 2019, IP: 114.125.76.19]
Sen, et al.: Norethisterone and OCP in dysfunctional uterine bleeding
Figure 2: Pictorial blood loss assessment chart in Bengali to assess amount
of blood loss during menstruation
in Bengali is shown in Figure  2. Patients were trained to
score the card during menstruation by a female expert.
A  particular brand sanitary pad/napkin with the same
absorbance was supplied to all the patients to reduce any
error. After one menstrual period, the patients appeared
in the hospital with the PBAC score and were recorded
in register with a number. Odd number patients were
designated in Group  I and even number was designated to
Group  II. This was practiced so that each patient has an
equal chance to be selected in two groups.
After assigning a patient to a particular group, she
undergone test for hemoglobin level in blood. Venous
blood was collected from an antecubital vein with aseptic
precaution. Then, the blood was transferred for analysis in
automated analyzer which uses spectrometric method of
hemoglobin estimation.
Treatment protocol
Norethisterone was provided to Group  I patients. The
dosage was 5 mg tablet, twice daily after food starting from
the 5th day of menstrual cycle to the 25th day of the cycle.
Low‑dose COC pill  (containing 30 mcg ethinylestradiol
and 150 mcg levonorgestrel) was provided to Group  II
patients. The dosage was 1 tablet after food, at the bedtime,
to take starting from the 5th  day of menstrual cycle to the
25th day of the cycle.
Both of the drugs were supplied by the institution where
the study was conducted.
Data collection
Demographics of the patients were recorded during
recruitment of the patients. Pretreatment PBAC score
and hemoglobin level were recorded on the first
follow‑up visit appearing with PBAC score  (i.e.,  before
CHRISMED Journal of Health and Research | Volume 6 | Issue 2 | April-June 2019
the group division). The PBAC on the 6th  cycle
after commencement of treatment was taken as the
posttreatment PBAC score. Posttreatment hemoglobin
level was tested after the 6th  cycle. These data were
stored for statistical analysis.
Statistical analysis
For the statistical analysis, α was set at 0.05. Categorical
variables were expressed in numbers and percentage of
patients and compared by Chi‑square test. Continuous
variables were expressed in mean and standard deviation.
For comparison of pre‑ and posttreatment PBAC score and
hemoglobin level, paired t‑test was used. For comparison
of improvement  (posttreatment–pretreatment) in PBAC
score and hemoglobin level, unpaired t‑test was used.
Statistical analysis was carried out in GraphPad Prism
version 6.01 (GraphPad Software, La Jolla, CA, USA).
Results
A total of 50  patients with a mean age
28.62 ± 9.84 years (range: 13–45 years, confidence interval:
25.82–31.42) comprised the Group  I  (i.e.,  group which
received norethisterone treatment) and a total of 50 patients
with a mean age 28.42  ±  10.08  years (range: 15–45  years,
confidence interval: 25.56–31.28) comprised the
Group  II  (i.e.,  group which received low‑dose COC pill
treatment). Age range‑wise distribution of patients with
their demographics is shown in Table 1.
Pre‑  and posttreatment PBAC score and hemoglobin in
Group  I and Group  II are shown in Table  2. There was
a statistically significant improvement of PBAC score
and hemoglobin after the treatment in both groups of
patients.
The improvements  (posttreatment–pretreatment values) in
PBAC score and hemoglobin level is shown in Table  3.
There was no significant difference in Group I and Group II
in terms of improvement in PBAC score and hemoglobin
level.
Side effects of the drugs, as reported by the patients,
are shown in Table  4. Nausea/vomiting was more
experienced with low‑dose COC (24% vs. 6%). In contrast,
irregular menstrual bleeding  (22% vs. 4%), weight gain
(20% vs. 6%), and  acne and hirsutism (12% vs. 0%) were
higher with norethisterone treatment.
Discussion
In this study, first, we evaluated the efficacy of
norethisterone in the improvement of blood loss in patients
presenting with DUB. It was observed that norethisterone
was able to reduce the PBAC score and increase the level
of hemoglobin after treatment of 6  months  [Table  2].
It has been reported that a significant number of Indian
women suffer from DUB and it has several negative
effects on physical, emotional, sexual, and professional
89
[Downloaded free from http://www.cjhr.org on Thursday, June 13, 2019, IP: 114.125.76.19]

Sen, et al.: Norethisterone and OCP in dysfunctional uterine bleeding

Table 1: Demographic details of the study patients in two intervention group

Patients treated with drug χ2, P
Norethisterone (n=50), n (%) Low‑dose COC pill (n=50), n (%)
Age group
13-21 16 (32) 16 (32) 0.06, 0.97
22-34 18 (36) 17 (34)
35-45 16 (32) 17 (34)
Marital status
Married 35 (70) 36 (72) 0.05, 0.83
Unmarried 15 (30) 14 (28)
Educational status
Up to primary 11 (22) 9 (18) 1.80, 0.61
Up to secondary 14 (28) 16 (32)
Up to higher secondary 19 (38) 15 (30)
Graduation and above 6 (12) 10 (20)
Residential area
Rural 21 (42) 19 (38) 1.17, 0.56
Semi‑urban 15 (30) 20 (40)
Urban 14 (28) 11 (22)
COC: Combined oral contraceptive

Table 2: Pretreatment and posttreatment pictorial blood assessment chart score and hemoglobin level
Parameter Patients treated with drug
Norethisterone (n=50) Mean±SD Low‑dose COC pill (n=50) Mean±SD
Pretreatment Posttreatment t, P Pretreatment Posttreatment t, P
PBAC score 176.16±5.75 77.80±5.76 89.16, <0.001* 175.58±6.07 78.88±8.51 77.21, <0.001*
Hemoglobin (gm/dL) 7.64±0.58 10.44±0.78 18.28, <0.001* 7.72±0.50 10.38±0.64 22.16, <0.001*
*Statistically significant P value of paired t‑test. COC: Combined oral contraceptive, PBAC: Pictorial blood assessment chart

Table 3: Improvements (difference between helps in regaining near‑normal level of menstrual bleeding.

posttreatment and pretreatment values) in PBAC score
and hemoglobin in two intervention groups
Parameter Patients treated with drug t, P*
Norethisterone Low‑dose COC pill
(n=50) Mean±SD (n=50) Mean±SD
PBAC score -98.62±7.82 -96.44±8.74 1.31, 0.19
Hemoglobin 2.75±1.06 2.71±0.86 0.21, 0.84
(gm/dL)
*t and P are of unpaired t‑test with α=0.05. PBAC: Pictorial blood
assessment chart, COC: Combined oral contraceptive,
SD: Standard deviation
life.[25,26] Hence, an evidence‑based first‑line treatment
is commonly provided by a general physician or family
physicians. If the management fails, the physician
may refer the patients to specialist doctor for further
evaluation.[27] A study conducted by Ashraf et  al. reported
that levonorgestrel‑containing intrauterine device  (IUD)
is better than the oral norethisterone.[28] However, IUD
acceptance still faces challenges.[29] In contrast, orally
taken drugs are easy to take with less side effects. It is still
obscure what causes DUB. However, a progesterone‑related
multiple morphological and functional endometrial changes
are frequently seen in patients presenting with DUB.[30]
Moreover, maintaining a sustained level of progesterone
Finding of the current study supports the efficacy of
norethisterone as a treatment mode in DUB.
In addition to the efficacy of norethisterone, this study also
supports the use of low‑dose COC pills in the improvement
of blood loss associated with DUB  [Table  2].[31] Previous
studies established the efficacy of COC in the treatment
of DUB.[16,17,32] In contrast to norethisterone, COC pills
contain both estrogen and progestogen. It is given for
3 weeks, and then, it is stopped for a week. In this pill‑free
week, women experience hormone withdrawal bleeding.
It significantly reduces the menstrual blood flow rate. If
otherwise not contraindicated, COC is widely accepted due
to its once in a day dosing.[33]
When the improvement level was compared between
the norethisterone and low‑dose COC pills, it was found
that there was no difference between the efficacies of
two methods  [Table  3]. Hence, a clinician may decide
anyone between these two methods. However, when
the side effects were evaluated  [Table  4], it was found
that the most common side effect of norethisterone was
irregular menstrual bleeding and most common side effect
of low‑dose COC was nausea/vomiting. Considering the
patient reported side effects, low‑dose COC stands at a
better position than the norethisterone. When patients come

90 CHRISMED Journal of Health and Research | Volume 6 | Issue 2 | April-June 2019
[Downloaded free from http://www.cjhr.org on Thursday, June 13, 2019, IP: 114.125.76.19]

Sen, et al.: Norethisterone and OCP in dysfunctional uterine bleeding

Table 4: Side effects as reported by patients during treatment

Side effects Patients treated with drug χ2, P
Norethisterone (n=50), n (%) Low‑dose COC pill (n=50), n (%)
Yes No Yes No
Nausea/vomiting 3 (6) 47 (94) 12 (24) 38 (86) 6.35, 0.01*
Irregular menstrual bleeding 11 (22) 39 (78) 2 (4) 48 (96) 7.16, 0.007*
Breakthrough bleeding 1 (2) 49 (98) 3 (6) 47 (94) 1.04, 0.31
Headache 4 (8) 46 (92) 3 (6) 47 (94) 0.15, 0.70
Breast tenderness 4 (8) 46 (92) 6 (12) 44 (88) 0.44, 0.51
Weight gain 10 (20) 40 (80) 3 (6) 47 (94) 4.33, 0.04*
Acne and hirsutism 6 (12) 44 (88) 0 50 (100) 6.38, 0.01*
*Statistically significant P value of Chi‑square test. COC: Combined oral contraceptive

with complaints of HMB, the presence of irregular bleeding Financial support and sponsorship
during treatment may be a reason of lower acceptance. Nil.
However, concluding on this issue was beyond the scope of
the current study. Conflicts of interest

Limitations of the study There are no conflicts of interest.

This study has several limitations. The subject of the References

study was recruited from a single tertiary care hospital.
For diagnosis of HMB, PBAC score was used which is
a semi‑subjective method of assessment. As the score
in PBAC was recorded by the patients, there may be
error in evaluation of the amount of blood. Ovulatory
and anovulatory DUB was not separately taken into
consideration. Posttreatment evaluation was done after
6  months. Further follow‑up was suggested to patients but
not included in this study due to the limitation of time.
The impact of treatment in the improvement of the quality
of life was not assessed. Furthermore, pain score was not
assessed in the study. These factors may be considered in
future studies.
Conclusion
Both norethisterone and low‑dose COC pills were found
to be equally effective in reduction of blood loss in DUB.
Considering the single dosage form and lower side effects,
low‑dose COC may be a better choice than norethisterone
for the management of DUB. Further studies are needed
to compare norethisterone and COC pills in compliance to
treatment for a prolonged period.
Acknowledgement
We thank the participating patients and their family
members for their cooperation in conduct of the study.
We are thankful to the nursing staff and our colleagues of
the Department of Gynecology and Obstetrics, Burdwan
Medical College and Hospital, West Bengal, India, for their
help and guidance during the study. We acknowledge the
help of Mrs. Sarika Mondal, Freelance Medical Writer,
ORCID: 0000‑0001‑5039‑9919, for her help during the
preparation of this manuscript.
1. Dysfunctional Uterine Bleeding. BMJ Best Practice.
Available from: https://www.bestpractice.bmj.com/topics/
en‑us/658#referencePop1. [Last accessed on 2018 Jun 05].
2. Bahamondes  L, Ali  M. Recent advances in managing and
understanding menstrual disorders. F1000Prime Rep 2015;7:33.
3. Thomas  MC. Treatment options for dysfunctional uterine
bleeding. Nurse Pract 2011;36:14‑20.
4. Livingstone  M, Fraser  IS. Mechanisms of abnormal uterine
bleeding. Hum Reprod Update 2002;8:60‑7.
5. Abnormal Uterine Bleeding. National Health Portal, Government
of India. Avaialble from: https://www.nhp.gov.in/disease/
gynaecology‑and‑obstetrics/abnormal‑uterine‑bleeding.  [Last
accessed on 2018 Jun 06].
6. Munro  MG. Dysfunctional uterine bleeding: Advances
in diagnosis and treatment. Curr Opin Obstet Gynecol
2001;13:475‑89.
7. What Is Abnormal Uterine Bleeding? WebMD. USA: WebMD
LLC. Avaialble from: https://www.webmd.com/women/
abnormal‑uterine‑bleeding. [Last accessed on 2018 Jun 10].
8. Higham  JM, O’Brien  PM, Shaw  RW. Assessment of menstrual
blood loss using a pictorial chart. Br J Obstet Gynaecol
1990;97:734‑9.
9. Reid  PC, Coker  A, Coltart  R. Assessment of menstrual
blood loss using a pictorial chart: A  validation study. BJOG
2000;107:320‑2.
10. Janssen CA, Scholten PC, Heintz AP. A simple visual assessment
technique to discriminate between menorrhagia and normal
menstrual blood loss. Obstet Gynecol 1995;85:977‑82.
11. Quinn  SD, Higham  J. Outcome measures for heavy menstrual
bleeding. Womens Health (Lond) 2016;12:21‑6.
12. Management of Acute Abnormal Uterine Bleeding in Nonpregnant
Reproductive‑Aged Women. USA: American College of
Obstetrician and Gynaecologist. Available from: https://www.acog.
org/Clinical-Guidance-and-Publications/Committee-Opinions/
Committee-on-Gynecologic-Practice/Management-of-Acute-
Abnormal-Uterine-Bleeding-in-Non pregnant-Reproductive-Aged-
Women. [Last accessed on 2018 Jun 11].
13. Pados  G, Athanatos  D, Tsolakidis  D, Stamatopoulos  P,
Tarlatzis B. Treatment options for dysfunctional uterine bleeding:

CHRISMED Journal of Health and Research | Volume 6 | Issue 2 | April-June 2019 91
[Downloaded free from http://www.cjhr.org on Thursday, June 13, 2019, IP: 114.125.76.19]
Sen, et al.: Norethisterone and OCP in dysfunctional uterine bleeding
Evaluation of clinical results. Gynecol Surg 2011;8:385.
14. Matteson  KA, Anderson  BL, Pinto  SB, Lopes  V, Schulkin  J,
Clark  MA, et al. Practice patterns and attitudes about treating
abnormal uterine bleeding: A national survey of obstetricians and
gynecologists. Am J Obstet Gynecol 2011;205:321.e1‑8.
15. Marret  H, Fauconnier  A, Chabbert‑Buffet  N, Cravello  L,
Golfier  F, Gondry  J, et al. Clinical practice guidelines on
menorrhagia: Management of abnormal uterine bleeding
before menopause. Eur J Obstet Gynecol Reprod Biol
2010;152:133‑7.
16. Mandal D, Parmanik S, Surana S, Hazra A, Mandal S, Maity TK.
Comparative study of low‑dose oral contraceptive pill and
ormeloxifene in the treatment of dysfunctional uterine bleeding.
Int J Health Allied Sci 2014;3:225‑31.
17. Lakkawar  NJ, Alaganandam  P, Yasodha  S. Efficacy of
ormeloxifene in comparison to oral contraceptive pills in medical
management of dysfunctional uterine bleeding. Int J Clin Trials
2016;3:244‑9.
18. Chhatrala JJ, Chawada R, Saini HB. Comparative study between
ormeloxifene and oral contraceptive pills in the treatment of
dysfunctional uterine bleeding. Int J Reprod Contracept Obstet
Gynecol 2015;4:366‑9.
19. Agarwal  N, Singh  S, Singh  S, Agarwal  M, Manocha  P.
Comparative evaluation of the efficacy and safety of
ormeloxifene and norethisterone in dysfunctional uterine
bleeding. Int J Reprod Contracept Obstet Gynecol 2013;2:194‑8.
20. Jacob  KJ, Mini, Deepak  AV. A  comparative study on the
effectiveness of ormeloxifene versus norethisterone in the
management of perimenopausal dysfunctional uterine bleeding.
Int Arch Integr Med 2015;2:87‑92.
21. Patel  NK, Patel  S, Damor  R, Pandya  MR. Comparison of
the efficacy and safety of norethisterone vs. combined oral
contraceptive pills for the management of puberty menorrhagia.
Int J Basic Clin Pharmacol 2012;1:191‑5.
22. Chauhan  M, Gupta  N, Dwivedi  S, Agarwal  S. A  study to
compare the efficacy of ormeloxifene with norethisterone and
conventional oral contraceptive pills. Int J Reprod Contracept
Obstet Gynecol 2017;6:4469‑72.
92 CHRISMED Journal of Health and Research | Volume 6 | Issue 2 | April-June 2019
23. Browner  WS, Newman  TB, Hulley  SB. Estimating sample size
and power: Applications and examples. In: Designing Clinical
Research. 3rd  ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2001. p. 66‑85.
24. WMA Declaration of Helsinki  –  Ethical Principles for Medical
Research Involving Human Subjects. France: World Medical
Association, Inc. Available from: https://www.wma.net/
policies-post/wma-declaration-of-helsinki-ethical-principles-for-
medical-research-involving-human-subjects/.  [Last accessed on
2018 Jun 12].
25. Benetti‑Pinto  CL, Rosa‑e‑Silva  AC, Yela Daniela  A, Soares
Júnior JM. Abnormal uterine bleeding. Rev Bras Ginecol Obstet
2017;39:358‑68.
26. Whitaker  L, Critchley  HO. Abnormal uterine bleeding. Best
Pract Res Clin Obstet Gynaecol 2016;34:54‑65.
27. Telner  DE, Jakubovicz  D. Approach to diagnosis and
management of abnormal uterine bleeding. Can Fam Physician
2007;53:58‑64.
28. Ashraf  MN, Habib‑Ur‑Rehman  A, Shehzad  Z, AlSharari  SD,
Murtaza G. Clinical efficacy of levonorgestrel and norethisterone
for the treatment of chronic abnormal uterine bleeding. J  Pak
Med Assoc 2017;67:1331‑8.
29. Cleland  J, Ali  M, Benova  L, Daniele  M. The promotion of
intrauterine contraception in low‑  and middle‑income countries:
A narrative review. Contraception 2017;95:519‑28.
30. Fraser  IS, Hickey  M, Song  JY. A  comparison of mechanisms
underlying disturbances of bleeding caused by spontaneous
dysfunctional uterine bleeding or hormonal contraception. Hum
Reprod 1996;11 Suppl 2:165‑78.
31. Farquhar C, Brown J. Oral contraceptive pill for heavy menstrual
bleeding. Cochrane Database Syst Rev 2009;4:CD000154.
32. Muneyyirci‑Delale  O, Gupta  A, Abraham  C, Chandrareddy  A,
Bowers CH Jr., Cutler  JB, et al. Management of dysfunctional
uterine bleeding based on endometrial thickness. Int J Womens
Health 2010;2:297‑302.
33. Maybin  JA, Critchley  HO. Medical management of heavy
menstrual bleeding. Womens Health (Lond) 2016;12:27‑34.