What is the initial approach to managing irregular menses (irregular menstrual cycles)?

From the Guidelines

The initial approach to managing irregular menses should prioritize identifying and addressing underlying causes, followed by symptomatic relief with options such as NSAIDs for short-term treatment or hormonal treatment if medically eligible, as recommended by the most recent guidelines 1. When managing irregular menses, it is crucial to first conduct a thorough medical evaluation to rule out underlying conditions such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions like polyps or fibroids, and treat or refer for care if an underlying condition is found 1.

Key Considerations

• For women experiencing irregular bleeding, the use of NSAIDs for 5–7 days can be considered for short-term treatment, regardless of the contraceptive method used 1.
• Hormonal treatment, such as low-dose combined oral contraceptives (COCs) or estrogen, can also be considered for short-term treatment (10–20 days) if the patient is medically eligible 1.
• Lifestyle modifications, including weight loss for women with obesity, regular exercise, stress management, and adequate sleep, may help regulate menstrual cycles, although these are more general recommendations and not specifically highlighted in the provided guidelines.

Treatment Options

• NSAIDs (e.g., ibuprofen) for 5–7 days can be used for spotting, light bleeding, or heavy/prolonged bleeding in users of various contraceptive methods, including Cu-IUD, LNG-IUD, implant, and injectable users 1.
• Hormonal treatment (e.g., low-dose COCs or estrogen) for 10–20 days may be considered for heavy or prolonged bleeding in implant users, among others, if medically eligible 1.
• Antifibrinolytic agents (e.g., tranexamic acid) for 5 days can also be considered for heavy or prolonged bleeding in certain cases 1. It's essential to tailor the approach to the individual patient's needs, preferences, and medical history, ensuring that any treatment option chosen is safe and effective for her specific situation, as emphasized in the guidelines 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 Use of oral contraceptives in the event of a missed menstrual period: If the patient has not 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 If the patient has adhered to the prescribed regimen and misses two consecutive periods, pregnancy should be ruled out before continuing oral contraceptive use.

The initial approach to managing irregular menses includes:

• Ruling out pregnancy or malignancy with adequate diagnostic measures in cases of undiagnosed persistent or recurrent abnormal bleeding from the vagina
• Considering time or a change to another preparation if both pregnancy and pathology have been excluded
• Changing to an oral contraceptive with a higher estrogen content may be considered to minimize menstrual irregularity, but this should be done only if necessary due to the increased risk of thromboembolic disease 2

From the Research

Initial Approach to Managing Irregular Menses

The initial approach to managing irregular menses involves a systematic evaluation to identify the underlying cause. This includes:

• A detailed history to assess menstrual onset and patterns, eating and exercise habits, presence of psychosocial stressors, body weight changes, medication use, and chronic illness 3, 4
• A physical examination to identify anthropometric and pubertal development trends 4
• Laboratory assessment, including a pregnancy test and serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone 3, 4

Common Causes of Irregular Menses

Common causes of irregular menses include:

• Polycystic ovary syndrome (PCOS) 3, 4, 5, 6
• Hypothalamic amenorrhea 3, 4
• Hyperprolactinemia 3
• Primary ovarian insufficiency 3, 4
• Outflow tract abnormalities 4
• Other endocrine gland disorders 4

Treatment Options

Treatment options for irregular menses depend on the underlying cause and may include:

• Hormone replacement therapy 4
• Contraception 4, 5, 6
• Infertility services 4
• Screening and intervention for metabolic disease and endometrial cancer risk in patients with PCOS 4, 6
• Addressing underlying causes such as disordered eating and low bone density in patients with functional hypothalamic amenorrhea 4