What alternatives to Gonadotropin-Releasing Hormone (GnRH) agonists can be used to suppress menstrual cycles in adolescents?

From the Guidelines

For managing menstrual periods in adolescents without using Gonadotropin-Releasing Hormone (GnRH) agonists, combined oral contraceptives (COCs) containing estrogen and progestin are the most effective option to suppress menstrual cycles. These can be used continuously to suppress menstruation, as supported by the study published in Pediatrics in 2014 1. Alternatively, progestin-only options like the Depo-Provera injection (given every 12 weeks) 1, hormonal IUDs (Mirena, Kyleena, which last 3-7 years) 1, or the etonogestrel implant (Nexplanon, effective for 3 years) can reduce or eliminate periods. These methods work by preventing ovulation and/or thinning the uterine lining, which reduces or eliminates menstrual bleeding.

Some key points to consider when prescribing these alternatives include:

• COCs have few contraindications in healthy female adolescents, but should not be prescribed for patients with severe and uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura or focal neurologic symptoms, thromboembolism or thrombophilia, complications of diabetes, and complicated solid organ transplantation 1.
• Progestin-only options like Depo-Provera may cause reductions in bone mineral density, but this risk can be mitigated with daily intake of calcium and vitamin D and regular weight-bearing exercise 1.
• IUDs are safe for nulliparous adolescents and do not cause tubal infertility, but may have a small risk of pelvic infection after insertion 1.
• HIV infection is not a contraindication to IUD use, but individuals with advanced HIV disease may need to use an alternative contraceptive method until their immunologic and clinical status improves with antiretroviral therapy 1.

Non-hormonal options include NSAIDs like ibuprofen (600-800mg three times daily during periods) to reduce flow by 20-40%, or tranexamic acid (1300mg three times daily during bleeding) which can reduce flow by up to 50% 1. These medications are generally safe for adolescents but should be prescribed by a healthcare provider who can consider the individual's medical history, needs, and preferences to determine the most appropriate option.

From the Research

Alternatives to GnRH Agonists for Menstrual Suppression

Alternatives to Gonadotropin-Releasing Hormone (GnRH) agonists for suppressing menstrual cycles in adolescents include:

• Contraceptive options:
  • Depot-medroxyprogesterone acetate 2
  • Levonorgestrel intrauterine systems 2
  • Progestin-only contraceptive pills 2, 3
  • Combined hormonal contraceptives 2, 4, 5, 3
• Non-contraceptive options:
  • Norethindrone acetate 2
  • Oral medroxyprogesterone acetate 2
  • Danazol 2
• Non-pharmacologic interventions:
  • Specialty menstrual underwear 2

Considerations for Adolescent Menstrual Suppression

When considering alternatives to GnRH agonists for menstrual suppression in adolescents, it is essential to:

• Involve the patient in shared decision-making 2
• Prioritize the patient's stated needs and desires 2
• Ensure accurate screening and frequent follow-up to reduce side effects and improve compliance 4
• Counsel patients about options for managing breakthrough bleeding, such as supplementation with intermittent estrogen or instituting a hormone-free interval 5