What are the diagnosis and treatment options for polymenorrhea?

Diagnosis and Treatment of Polymenorrhea

Polymenorrhea should be treated with combined oral contraceptives (COCs) as first-line therapy, which effectively regulate menstrual cycles while providing additional benefits including decreased menstrual cramping and reduced blood loss. 1

Definition and Diagnosis

Polymenorrhea is defined as abnormally frequent menstrual cycles occurring at intervals of less than 21 days. Diagnosis requires:

• Documentation of menstrual cycle frequency (cycles occurring <21 days apart)
• Exclusion of pregnancy (mandatory first step)
• Assessment of underlying causes

Diagnostic Workup

1. Initial laboratory evaluation:

   • Pregnancy test
   • Serum levels of:
     • Luteinizing hormone (LH)
     • Follicle-stimulating hormone (FSH)
     • Prolactin
     • Thyroid-stimulating hormone (TSH)

2. Additional testing based on clinical suspicion:

   • Transvaginal ultrasonography (if structural abnormalities suspected)
   • Serum androgen levels (if hyperandrogenism suspected)
   • Pelvic imaging (if anatomical causes suspected)

Common Causes of Polymenorrhea

Hormonal Causes

• Anovulation
• Polycystic ovary syndrome (PCOS)
• Thyroid dysfunction
• Hyperprolactinemia
• Perimenopause

Structural Causes

• Uterine fibroids
• Endometrial polyps
• Adenomyosis

Other Causes

• Stress
• Excessive exercise
• Significant weight changes
• Medications (anticoagulants, hormonal treatments)

Treatment Algorithm

First-Line Treatment

• Combined oral contraceptives (COCs) containing 30-35 μg ethinyl estradiol with progestins such as levonorgestrel or norgestimate 1
  • Benefits: Regulates cycles, reduces blood loss, decreases menstrual cramping
  • Standard regimen: 21-24 hormone pills followed by 4-7 placebo pills
  • Consider extended or continuous cycles for severe symptoms

Alternative Treatments Based on Underlying Cause

For PCOS-Related Polymenorrhea

• COCs (first-line)
• Metformin (insulin-sensitizing agent) 2
  • Improves insulin sensitivity
  • Decreases circulating androgens
  • Improves ovulation frequency
• Weight loss if overweight/obese (improves insulin sensitivity) 2

For Anovulatory Bleeding Without PCOS

• COCs (first-line)
• Cyclic progestin therapy (medroxyprogesterone acetate) 2
  • Note: Less effective than COCs for regulating cycles

For Structural Causes

• Medical management with COCs or progestins first
• Consider surgical intervention if medical management fails:
  • Hysteroscopic removal of polyps
  • Myomectomy for fibroids
  • Endometrial ablation for persistent abnormal bleeding

For Patients with Contraindications to COCs

• Progestin-only contraceptives
• Levonorgestrel intrauterine system (LNG-IUD)
• Non-hormonal options:
  • NSAIDs during days of bleeding (short-term treatment for 5-7 days) 2
  • Tranexamic acid

Management of Side Effects

Bleeding Irregularities with Treatment

• Unscheduled spotting or light bleeding is common, especially with hormonal treatments
• If persistent and bothersome:
  • Rule out underlying gynecological problems
  • Consider NSAIDs for short-term treatment (5-7 days) 2
  • If unacceptable to patient, consider alternative contraceptive methods

Heavy or Prolonged Bleeding

• Rule out underlying gynecological problems
• Treatment options during days of bleeding:
  • NSAIDs for short-term treatment (5-7 days)
  • Hormonal treatment with low-dose COCs for short-term treatment (10-20 days) 2

Special Considerations

Adolescents

• Irregular cycles are common in the first 2-3 years after menarche
• Consider watchful waiting if no concerning symptoms
• COCs are safe and effective for adolescents with persistent polymenorrhea

Perimenopausal Women

• Polymenorrhea may be an early sign of perimenopause
• Consider hormonal treatments to regulate cycles and manage symptoms

Women with Metabolic Risk Factors

• Screen for metabolic abnormalities in women with PCOS
• Fasting glucose, lipid profile recommended 2
• Consider metformin for women with insulin resistance

Follow-up Recommendations

• Evaluate response to treatment after 3 months
• If no improvement, reassess diagnosis and consider alternative treatments
• Annual follow-up for women with well-controlled symptoms
• More frequent monitoring for those with persistent symptoms or underlying conditions

Warning Signs Requiring Urgent Evaluation

• Severe heavy bleeding with anemia
• Sudden change in bleeding pattern
• Postcoital bleeding
• Intermenstrual bleeding in women >40 years

By following this structured approach to diagnosis and treatment, polymenorrhea can be effectively managed in most patients, improving quality of life and preventing complications.