What is the initial management approach for a patient presenting with irregular menses (oligomenorrhea or polymenorrhea)?

From the Guidelines

The initial management of irregular menses (oligomenorrhea or polymenorrhea) should begin with a comprehensive evaluation to identify the underlying cause, and treatment options may include hormonal contraceptives, NSAIDs, or alternative contraceptive methods, as indicated by the patient's symptoms and preferences 1.

Initial Evaluation

The evaluation should include a detailed history, physical examination, and targeted laboratory testing to identify the underlying cause of irregular menses. This may involve:

• Obtaining a thorough menstrual history, sexual history, and medication use
• Assessing for symptoms of thyroid dysfunction, hyperprolactinemia, or hyperandrogenism
• Laboratory tests, such as pregnancy test, complete blood count, thyroid-stimulating hormone, prolactin, and total testosterone and free testosterone in cases of suspected polycystic ovary syndrome (PCOS)

Treatment Options

Treatment options for irregular menses may include:

• Hormonal contraceptives, such as combined oral contraceptives (e.g., ethinyl estradiol 20-35 mcg with progestin), which are first-line therapy to regulate cycles and provide endometrial protection for patients with oligomenorrhea who are not seeking pregnancy 1
• NSAIDs, such as ibuprofen (600-800 mg three times daily during menses), which can reduce bleeding in patients with polymenorrhea
• Alternative contraceptive methods, such as levonorgestrel IUD, which can provide longer-term management for patients with polymenorrhea
• If structural abnormalities are suspected, pelvic ultrasound should be performed to further evaluate the patient's condition 1

Patient-Centered Approach

Treatment should be tailored to the underlying etiology, patient's reproductive goals, and preference. Regular follow-up is essential to assess treatment efficacy and adjust management as needed. This approach addresses both symptom management and the prevention of potential complications like endometrial hyperplasia in patients with chronic anovulation. The most recent and highest quality study 1 supports the use of hormonal contraceptives as a first-line treatment option for patients with oligomenorrhea, highlighting the importance of a patient-centered approach to managing irregular menses.

From the Research

Initial Management Approach for Irregular Menses

The initial management approach for a patient presenting with irregular menses, including oligomenorrhea or polymenorrhea, involves a systematic evaluation to identify the underlying cause.

• A detailed history, including menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, and galactorrhea, should be taken 2.
• A physical examination should be performed to identify anthropometric and pubertal development trends 2.
• A pregnancy test should be offered to all patients, as pregnancy is a common cause of secondary amenorrhea 3, 2.
• Serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH) should be assessed to evaluate the hypothalamic-pituitary-ovarian axis 3, 2.

Potential Causes of Irregular Menses

Potential causes of irregular menses include:

• Polycystic ovary syndrome (PCOS), which is a frequent cause of menstrual disorders in adolescent girls 4.
• Hypothalamic amenorrhea, which may indicate disordered eating and low bone density 3, 2.
• Primary ovarian insufficiency, which can maintain unpredictable ovarian function and may require hormone replacement therapy, contraception, or infertility services 3, 2.
• Other endocrine gland disorders, such as hyperprolactinemia or thyroid disorders 3, 2.

Additional Evaluation and Management

Additional evaluation and management may be necessary depending on the underlying cause of irregular menses.

• For example, patients with PCOS should undergo screening and intervention to attenuate metabolic disease and endometrial cancer risk 2.
• Patients with hypothalamic amenorrhea should be evaluated for eating disorders and are at risk for decreased bone density 3, 2.
• Hormonal therapies, such as combined hormonal contraceptives, may be used to manage irregular menses and reduce the risk of endometrial hyperplasia 5.