What is the best approach to manage menorrhagia in a 17-year-old patient with a history of migraine with aura who is currently on Slynd (drospirenone)

From the Guidelines

For a 17-year-old patient with menorrhagia who has migraines with aura and is currently taking Slynd (drospirenone), the best approach would be to continue Slynd and add a non-hormonal treatment such as tranexamic acid (Lysteda) 1300 mg three times daily during heavy bleeding days. This approach is based on the fact that Slynd is a progestin-only pill without estrogen, making it safe for patients with migraines with aura who have contraindications to estrogen-containing contraceptives 1. The management of menorrhagia in this patient should prioritize treatments that do not exacerbate migraine symptoms. Key considerations include:

• Continuing Slynd to maintain contraception without estrogen, which can worsen migraines with aura
• Adding tranexamic acid for its efficacy in reducing menstrual blood loss by approximately 40-60% without affecting migraine management
• Considering non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen for additional bleeding reduction and pain relief, although their impact on migraine should be monitored
• Iron supplementation, such as ferrous sulfate 325 mg daily, if signs of iron deficiency anemia are present, to improve quality of life by reducing fatigue and other anemia-related symptoms. It's crucial to follow up regularly to assess the effectiveness of these treatments and consider further interventions, such as endometrial assessment, if menorrhagia persists. The guidance on migraine management 1 emphasizes the importance of preventive treatment and the use of specific medications, but in the context of menorrhagia treatment, the focus remains on balancing effective bleeding control with safe and effective contraception, while considering the patient's migraine condition.

From the Research

Management of Menorrhagia in a 17-year-old Patient

• The patient is currently on Slynd (drospirenone) and has a history of migraine with aura, which can impact the management of menorrhagia 2.
• Menorrhagia is a common condition in women of reproductive age and can be associated with migraine, as evidenced by a study that found a higher frequency of menorrhagia in female migraineurs compared to age-matched women without headache 3.
• The use of combined oral contraceptives, such as Slynd, can be beneficial in reducing menstrual blood loss and managing menorrhagia, but may not be suitable for all patients, particularly those with a history of migraine with aura 2.

Treatment Options for Menorrhagia

• Tranexamic acid is an effective and well-tolerated treatment for idiopathic menorrhagia, reducing menstrual blood loss by 34-59% over 2-3 cycles 4.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) and other medications, such as mefenamic acid and flurbiprofen, may also be used to manage menorrhagia, but may not be as effective as tranexamic acid 4.
• Hormonal therapies, such as levonorgestrel, can also be effective in reducing menstrual blood loss, but may have adverse effects and are not suitable for all patients 4.

Considerations for Migraine with Aura

• The patient's history of migraine with aura is a significant consideration in the management of menorrhagia, as combined oral contraceptives may be contraindicated in patients with migraine with aura 2.
• Alternative treatments, such as tranexamic acid, may be more suitable for patients with migraine with aura, but the effectiveness and safety of these treatments in this population need to be carefully evaluated 4.
• The patient's migraine treatment plan should be taken into account when managing menorrhagia, and prophylactic strategies, such as perimenstrual prophylaxis, may be necessary to reduce the frequency and severity of migraine attacks 5, 6.