What treatment options are available for irregular menstrual bleeding related to estrogen levels?

From the Guidelines

Treatment for irregular menstrual bleeding related to estrogen levels should prioritize hormonal and non-hormonal approaches that address the underlying hormonal imbalance and reduce blood loss, with options including NSAIDs, hormonal treatment with low-dose COCs or estrogen, and lifestyle modifications. When considering treatment options, it's essential to first rule out any underlying gynecological problems, such as interactions with other medications, STDs, pregnancy, or new pathologic uterine conditions like polyps or fibroids, as recommended by 1 and 1. If an underlying gynecologic problem is not found and the woman wants treatment, the following options can be considered:

• NSAIDs for short-term treatment (5–7 days)
• Hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days), as suggested by 1 and 1. Additionally, lifestyle modifications such as maintaining a healthy weight, regular exercise, and stress management can help regulate estrogen levels naturally. It's also important to note that if irregular bleeding persists and is unacceptable to the patient, the clinician should assist with choosing another contraceptive method, as recommended by 1. Overall, the choice of treatment depends on the severity of symptoms, underlying causes, and whether fertility preservation is desired, and should be guided by the most recent and highest quality evidence, such as 1, 1, and 1.

From the FDA Drug Label

Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use Non-hormonal causes should be considered and adequate diagnostic measures taken to rule out malignancy or pregnancy in the event of breakthrough bleeding, as in the case of any abnormal vaginal bleeding. If pathology has been excluded, time or a change to another formulation may solve the problem.

Treatment options for irregular menstrual bleeding related to estrogen levels include:

• Changing to an oral contraceptive with a higher estrogen content, but this should be done only if necessary due to the increased risk of thromboembolic disease 2
• Time: allowing the body to adjust to the current oral contraceptive formulation
• Changing to another preparation: switching to a different oral contraceptive formulation may help solve the problem of irregular menstrual bleeding 2
• Adequate diagnostic measures: ruling out pregnancy or malignancy before considering a change in treatment 2 2

From the Research

Treatment Options for Irregular Menstrual Bleeding Related to Estrogen Levels

• The treatment of irregular menstrual bleeding related to estrogen levels depends on the underlying cause, which can be anovulatory or ovulatory patterns 3, 4.
• For anovulatory bleeding, treatment options include combination oral contraceptives or progestins to regulate menstrual cycles 3.
• Histologic findings of hyperplasia without atypia may be treated with cyclic or continuous progestin 3.
• Ovulatory abnormal uterine bleeding, or menorrhagia, may be caused by thyroid dysfunction, coagulation defects, endometrial polyps, and submucosal fibroids, and can be treated with the levonorgestrel-releasing intrauterine system, oral progesterone, nonsteroidal anti-inflammatory drugs, or tranexamic acid 3, 5.
• In some cases, surgical interventions such as polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation may be considered 3.
• Progesterone and progestogens play a crucial role in the management of abnormal uterine bleeding, and can be used to regulate intermenstrual bleeding and decrease heavy menstrual bleeding in women of reproductive age or who are perimenopausal 6.
• Medical management is the first-line approach for abnormal uterine bleeding, and determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen 5.

Medical Management of Abnormal Uterine Bleeding

• Parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options for acute abnormal uterine bleeding with a normal uterus 5.
• Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy 5.
• Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding 5.
• Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions 5.

Role of Progesterone in Abnormal Uterine Bleeding

• Progesterone acts in concert with other hormones to affect breast, cardiovascular system, lipid profile, and bone, and its unintended side effects may be used beneficially or may cause intended side effects 6.
• Progesterone and progestogens prevent endometrial hyperplasia and aim to reduce the development of endometrial cancer in menopausal women 6.