What are the management options for a patient who started her menstrual period yesterday?

From the Guidelines

For a patient who started her menstrual period yesterday, the most appropriate management option is to start combined hormonal contraceptives immediately if it is reasonably certain that the woman is not pregnant, without waiting for her next menstrual period. This approach is supported by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013, adapted from the World Health Organization 1. The key consideration is the timing and the need for backup contraception.

• If it has been less than or equal to 5 days since menstrual bleeding started, no additional contraceptive protection is needed for the next 7 days.
• However, if it has been more than 5 days since menstrual bleeding started, the patient should abstain from sexual intercourse or use additional contraceptive protection for the next 7 days. For patients switching from an IUD, special considerations apply, including the option to retain the IUD for at least 7 days after initiating combined hormonal contraceptives, abstaining from sexual intercourse or using barrier contraception for 7 days before removing the IUD, or using emergency contraceptive pills at the time of IUD removal, as outlined in the recommendations 1.
• Non-pharmacological approaches such as heat therapy and lifestyle modifications can also be beneficial for symptom management.
• The choice of management should be individualized based on the patient's specific needs, medical history, and preferences, prioritizing morbidity, mortality, and quality of life as outcomes.

From the FDA Drug Label

For the treatment of dysmenorrhea, beginning with the earliest onset of such pain, ibuprofen tablets should be given in a dose of 400 mg every 4 hours as necessary for the relief of pain. The management option for a patient who started her menstrual period yesterday is to take ibuprofen 400 mg every 4 hours as needed for pain relief, starting from the onset of pain, for the treatment of dysmenorrhea 2.

• The dose can be adjusted based on individual patient needs.
• It is essential to follow the recommended dosage and not exceed the maximum daily dose of 3200 mg.

From the Research

Management Options for Heavy Menstrual Bleeding

The patient who started her menstrual period yesterday may be experiencing heavy menstrual bleeding, which can be managed through various medical therapies. Some of the options include:

• Oral contraceptive pills (OCP) to reduce menstrual blood loss and provide contraception 3, 4, 5
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid and naproxen to reduce menstrual blood loss and pain 4, 6
• Antifibrinolytics such as tranexamic acid to reduce menstrual blood loss 6
• Levonorgestrel-releasing intrauterine system (LNG IUS) to reduce menstrual blood loss and provide contraception 4
• Vitamin B1 to reduce menstrual blood loss and pain 6

Effectiveness of Combined Hormonal Contraceptives

Combined hormonal contraceptives, such as the combined oral contraceptive pill (COCP) and the contraceptive vaginal ring (CVR), have been shown to be effective in reducing heavy menstrual bleeding 4. The COCP has been found to reduce menstrual blood loss and improve treatment success compared to placebo 4. However, the evidence is limited, and more research is needed to determine the effectiveness of combined hormonal contraceptives compared to other medical therapies.

Treatment and Prevention of Heavy Menstrual Bleeding and Pain

Various interventions have been studied for the treatment and prevention of heavy menstrual bleeding and pain associated with intrauterine device (IUD) use 6. These include NSAIDs, anti-fibrinolytics, and paracetamol. The evidence suggests that vitamin B1 and mefenamic acid may be effective in treating heavy menstruation, while tolfenamic acid may be effective in preventing heavy menstruation associated with copper IUD use.

Relationship between Heavy Menstrual Bleeding, Iron Deficiency, and Iron Deficiency Anemia

Heavy menstrual bleeding is a major contributor to iron deficiency and iron deficiency anemia in reproductive-aged women 7. Iron deficiency can have significant effects on cognitive function, work and school absenteeism, and presenteeism. It is essential to raise awareness of this underappreciated situation and to develop evidence-based changes in clinical guidance and healthcare policy to prevent, screen, diagnose, and manage both heavy menstrual bleeding and iron deficiency.