Management of Menstrual Irregularities and Disorders
The management of menstrual irregularities should begin with proper identification of the underlying cause through specific diagnostic tests, followed by targeted treatment that may include hormonal contraceptives, NSAIDs, or lifestyle modifications depending on the specific disorder identified. 1
Diagnostic Approach
Clinical Features to Identify
- Menstrual irregularity patterns:
- Polymenorrhea: cycles <23 days
- Oligomenorrhea: cycles >35 days
- Amenorrhea: no bleeding for >6 months 2
- Associated symptoms:
- Infertility
- Weight gain/obesity
- Hirsutism
- Galactorrhea 2
Key Investigations
Hormonal Measurements:
- LH, FSH (days 3-6 of cycle)
- Prolactin (morning resting levels)
- Progesterone (mid-luteal phase)
- Testosterone and androstenedione
- DHEAS 2
Imaging Studies:
- Transvaginal ultrasound (more sensitive than transabdominal)
- Pituitary MRI if hyperprolactinemia is suspected 2
Metabolic Assessment:
- Fasting glucose/insulin ratio 2
Treatment Algorithms by Condition
1. Polycystic Ovary Syndrome (PCOS)
PCOS affects 10-25% of women with temporal lobe epilepsy and 4-6% of the general population 2, 3
Treatment approach:
- First-line for overweight/obese patients: Dietary and lifestyle modifications 3
- For women not seeking fertility: Combined low-dose hormonal contraception (reduces menstrual blood loss by up to 50%) 1, 3
- For women who cannot take combined hormonal contraception: Progestin-only options or metformin 3
- For women attempting conception: Metformin to improve ovulation rates 3
2. Menorrhagia (Heavy Menstrual Bleeding)
Treatment options:
- NSAIDs (e.g., ibuprofen, mefenamic acid): 400mg every 4-6 hours during days of bleeding, reducing blood loss by approximately 20% 1, 4
- Hormonal treatments:
- Tranexamic acid: Non-hormonal option for abnormal bleeding 1
3. Hypothalamic Amenorrhea
Affects approximately 12% of women with temporal lobe epilepsy versus 1.5% in general population 2
Treatment approach:
- Hormonal replacement therapy
- Address underlying causes (stress, excessive exercise, weight loss)
4. Dysmenorrhea
Treatment options:
- NSAIDs: Ibuprofen 400mg every 4 hours at earliest onset of pain 4
- Combined hormonal contraceptives: Effective for long-term management 1
Special Considerations
Contraindications to Combined Hormonal Contraceptives
- History of arterial thromboembolic disease
- Breast cancer or other estrogen/progestin-sensitive cancers
- Uncontrolled hypertension or liver disease
- History of deep vein thrombosis or pulmonary embolism
- Migraine with aura if >35 years of age
- Smoking if >35 years of age 1
Monitoring and Follow-up
- Assess response after 3 months of therapy
- Monitor for side effects of medications
- Consider referral for surgical management for persistent symptoms 1
Complementary Approaches
- Yoga Nidra has shown benefits in reducing psychological problems associated with menstrual disorders and can be prescribed as an adjunct to conventional therapy 6
Important Caveats
- Menstrual irregularities are an important health indicator associated with various conditions including metabolic syndrome, coronary heart disease, type 2 diabetes, and rheumatoid arthritis 7
- Stress, particularly during examination periods, can significantly impact menstrual regularity 8
- For adolescents with heavy menstrual bleeding, consider screening for bleeding disorders, particularly von Willebrand disease 5
- Early recognition and treatment can prevent complications such as anemia, need for blood transfusion, and hospitalization 5
By following this structured approach to diagnosis and treatment, most menstrual irregularities can be effectively managed, significantly improving quality of life and preventing long-term health consequences.