From the Guidelines
For a patient presenting with one irregular menstrual period, watchful waiting is the recommended initial approach rather than immediate intervention. A thorough history should be taken, including details about the patient's typical cycle length and regularity, recent stressors, changes in weight, exercise habits, and medication use. A physical examination and pregnancy test should be performed to rule out pregnancy as a cause 1. If the patient has no concerning symptoms such as severe pain, heavy bleeding, or signs of anemia, reassurance and monitoring for 2-3 more cycles is appropriate. Menstrual irregularity often resolves spontaneously as many factors can temporarily disrupt the hypothalamic-pituitary-ovarian axis, including stress, illness, travel, or weight changes.
Key Considerations
- A patient's history and physical examination are crucial in determining the next steps in management
- Pregnancy should be ruled out as a cause of irregular menstrual period
- If irregularity persists beyond 3 months or is accompanied by symptoms like hirsutism, significant weight changes, galactorrhea, or if the patient has risk factors for endocrine disorders, further evaluation is warranted
Further Evaluation
If further evaluation is needed, hormone testing (TSH, prolactin, androgens) and possibly pelvic ultrasound should be considered 1. The investigation of women with symptoms or signs of reproductive endocrine disorder, such as polycystic ovary syndrome (PCOS), should include measurement of serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, progesterone, testosterone, and androstenedione.
Management Options
For patients desiring cycle regularity, combined hormonal contraceptives can be considered if there are no contraindications, as they provide predictable withdrawal bleeding and can address symptoms like heavy bleeding or dysmenorrhea. The goal of management should be to improve the patient's quality of life, reduce morbidity, and prevent mortality, while also addressing any underlying conditions that may be contributing to the irregular menstrual period.
From the FDA Drug Label
If the patient has adhered to the prescribed schedule, the possibility of pregnancy should be considered at the time of the first missed period and oral contraceptive use should be discontinued until pregnancy is ruled out The recommended evaluation for a patient presenting with one irregular menstrual period is to consider the possibility of pregnancy and discontinue oral contraceptive use until pregnancy is ruled out.
- The patient should be evaluated for pregnancy at the time of the first missed period.
- Oral contraceptive use should be discontinued until pregnancy is ruled out. 2
From the Research
Evaluation and Management of Irregular Menstrual Periods
For a patient presenting with one irregular menstrual period, the recommended evaluation and management approach includes:
- Obtaining a thorough medical history and performing a physical examination, as emphasized in the study on menstrual irregularities 3
- Understanding the characteristics of the menstrual cycle to determine the etiology of the irregularity
- Considering the differential diagnosis of irregular menstrual cycles, as discussed in the study on menstrual irregularities 3
Diagnostic Approach
The diagnostic approach may involve:
- A pregnancy test by an hCG assay, as recommended in the study on menorrhagia management 4
- A speculum examination and Pap smear to rule out any cervical disease, as suggested in the study on menorrhagia management 4
- Pelvic ultrasound, both abdominal and transvaginal, as a first-line procedure for the etiological diagnosis of abnormal uterine bleeding, as recommended in the study on menorrhagia management 4
Treatment Options
Treatment options for irregular menstrual periods may include:
- Hormonal contraceptives, such as combined oral contraceptive pills, which can help regulate menstrual cycles and improve symptoms associated with hormonal changes, as discussed in the study on contraception selection 5
- Other medical treatments, such as tranexamic acid or nonsteroidal anti-inflammatory drugs (NSAIDs), which may be used to manage heavy menstrual bleeding or other symptoms, as mentioned in the study on menorrhagia management 4