What is the initial management for a patient with irregular menstruation?

Initial Management of Irregular Menstruation

The initial management for irregular menstruation should include a systematic evaluation with laboratory assessment of hormone levels (including LH, FSH, prolactin, and TSH), pregnancy testing, and consideration of oral contraceptives for cycle regulation in appropriate candidates. 1, 2

Diagnostic Approach

Initial Assessment

• Pregnancy testing should be performed for:
  • Missed menses
  • Irregular bleeding
  • New onset of irregular bleeding after prolonged amenorrhea
  • New onset pelvic pain
  • Enlarged uterus or adnexal mass on examination 3

Laboratory Evaluation

• First-line laboratory tests:
  • Pregnancy test
  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
  • Prolactin
  • Thyroid-stimulating hormone (TSH) 2
  • Consider testosterone levels if signs of hyperandrogenism are present 3

Additional Evaluation

• Pelvic ultrasound if structural causes are suspected (particularly in women with heavy bleeding) 4
• Endometrial biopsy for:
  • Women ≥35 years with recurrent anovulation
  • Women <35 years with risk factors for endometrial cancer
  • Women with excessive bleeding unresponsive to medical therapy 4

Treatment Options

For Anovulatory Bleeding

1. Combined oral contraceptives (COCs) - first-line option:

   • Monophasic COC with 30-35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
   • Benefits include decreased menstrual cramping, blood loss, improvement in acne, and regulation of irregular cycles 1

2. Progestins (if estrogen is contraindicated):

   • Cyclic or continuous administration
   • Particularly effective for endometrial hyperplasia without atypia 4

3. Levonorgestrel-releasing intrauterine system (LNG-IUD) - effective for menorrhagia 4

   • Approximately 50% of users experience amenorrhea or oligomenorrhea by 2 years 1

For Ovulatory Heavy Bleeding (Menorrhagia)

1. NSAIDs - Ibuprofen 600-800 mg every 6-8 hours with food for the first 24-48 hours 1
2. Tranexamic acid - Effective but expensive 4
3. LNG-IUD - Most effective medical treatment for menorrhagia 4
4. Combined oral contraceptives - Effective for regulating cycles and reducing blood loss 1

Special Considerations

Polycystic Ovary Syndrome (PCOS)

• Common cause of irregular menstruation (10-25% prevalence in women with temporal lobe epilepsy) 3
• Characterized by hyperandrogenism, hirsutism, follicular arrest, and ovarian acyclicity 3
• Patients should be monitored for glucose intolerance and dyslipidemia 2

Hypothalamic Amenorrhea

• Evaluate for eating disorders
• Monitor bone density 2

Primary Ovarian Insufficiency

• Patients may maintain unpredictable ovarian function
• Should not be presumed infertile 2

Common Pitfalls to Avoid

1. Assuming all irregular menstruation in adolescents is physiologic

   • While irregular cycles are common in the first 3 years after menarche, pathology should still be considered 5

2. Overlooking systemic conditions

   • Irregular menstruation can be associated with metabolic syndrome, coronary heart disease, type 2 diabetes, and other conditions 6

3. Failure to consider structural causes

   • Endometrial polyps and submucosal fibroids can cause menorrhagia 4

4. Inadequate follow-up

   • Regular follow-up is essential to assess treatment response and address persistent adverse effects or adherence issues 1

Irregular menstruation serves as an important health indicator for women and should be properly evaluated and managed to prevent associated physical, mental, and reproductive problems 6.