What is the appropriate management for a 32-year-old female presenting with menorrhagia (excessive menstrual bleeding), reporting heavy menstrual flow for 3 days, using 8 tampons per day, and requesting the Depo (medroxyprogesterone acetate) injection, with a history of using her husband's semaglutide (semaglutide) and denying a family history of medullary thyroid cancer or pancreatitis?

From the Guidelines

The patient's request for the depot injection should be considered in the context of her heavy menstrual bleeding, and according to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use, hormone-free interval for 3–4 consecutive days may be an option for injectable (DMPA) users with heavy or prolonged bleeding 1. The patient is a 32-year-old female presenting to clinic with concerns about excessive menstrual bleeding. She reports having a normal 5-day menstrual cycle, but notes that as she ages, the first three days have become increasingly heavy, requiring approximately 8 tampons per day. Some key points to consider in her history include:

• The patient's heavy menstrual bleeding, defined as requiring 8 tampons per day for the first three days of her cycle
• Her request for the depot injection, which may be an appropriate management option for her heavy menses, as suggested by the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1
• The patient's unauthorized use of her husband's semaglutide, which may have implications for her medical management and potential interactions with other medications
• Her denial of any family history of medullary thyroid cancer or pancreatitis, which is relevant to her medical history and potential risk factors The patient's goals and preferences should be taken into account when determining the best course of management for her heavy menstrual bleeding, and exploring patient goals, including continued method use or method discontinuation, is recommended 1. Some potential treatment options for the patient's heavy menstrual bleeding may include:
• Hormone-free interval for 3–4 consecutive days, as suggested by the 2024 U.S. Selected Practice Recommendations for Contraceptive Use for injectable (DMPA) users with heavy or prolonged bleeding 1
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for 5–7 days, which may be used to treat spotting or light bleeding, as well as heavy or prolonged bleeding, in users of various contraceptive methods, including injectable (DMPA) users 1

From the FDA Drug Label

Most women using Medroxyprogesterone Acetate Injectable Suspension, USP experience disruption of menstrual bleeding patterns. Altered menstrual bleeding patterns include irregular or unpredictable bleeding or spotting, or rarely, heavy or continuous bleeding The patient is a 32-year-old female presenting with excessive menses, reporting a normal menstrual cycle of 5 days, but with heavy bleeding for 3 days, using 8 tampons a day. She requests the Depo injection.

• Chief Complaint: Excessive menses
• History of Present Illness: The patient reports a normal menstrual cycle duration of 5 days, but with heavy bleeding for 3 days, using 8 tampons a day. She denies a family history of medullary thyroid cancer or pancreatitis. 2

From the Research

History of Present Illness

The patient is a 32-year-old female presenting with complaints of excessive menstrual bleeding. She reports that her menstrual cycle typically lasts for 5 days, which is normal for her, but she has noticed an increase in heaviness over the years. Specifically, she experiences heavy bleeding for the first 3 days of her cycle, requiring 8 tampons per day.

Menstrual History

• The patient's menstrual cycle lasts for 5 days
• Heavy bleeding for the first 3 days
• Requires 8 tampons per day
• No reported history of medullary thyroid cancer or pancreatitis in her family

Current Requests

• The patient has requested the Depo injection
• She has also requested a compounded version of semaglutide, which she would like to be called in to Raff and Hall, and sent to the pharmacy
• She has been using her husband's semaglutide

Relevant Studies

The patient's symptoms are consistent with heavy menstrual bleeding (HMB), which is defined as excessive menstrual blood loss that interferes with a woman's physical, emotional, social wellbeing, and quality of life 3. The evaluation of HMB should include a menstrual and gynaecological history, a bleeding score, and a pelvic examination to rule out underlying pathology 3, 4. Medical therapies, such as hormonal treatments, levonorgestrel-releasing intrauterine system (LNG-IUS), and combined hormonal contraceptives, are commonly used to manage HMB 3, 5, 6. Haemostatic therapies, including tranexamic acid, may also be used to reduce menstrual blood loss 3, 4, 6.

Assessment and Management

The patient's history and symptoms suggest that she may benefit from medical management of her HMB, such as hormonal therapies or haemostatic agents 7, 3, 6. Further evaluation, including a pelvic examination and laboratory assessment, may be necessary to determine the underlying cause of her HMB and to develop an effective treatment plan 7, 3, 4.