Is Seasonale (levonorgestrel/ethinyl estradiol) suitable for a 41-year-old woman with irregular and heavy menstrual bleeding?

Management of Irregular and Heavy Periods with Seasonale in a 41-Year-Old Woman

Seasonale (levonorgestrel/ethinyl estradiol) is an appropriate option for a 41-year-old woman with irregular and heavy menstrual bleeding, provided she has no contraindications such as antiphospholipid antibodies or other thrombotic risk factors.

Initial Assessment Before Prescribing Seasonale

• Rule out underlying gynecological problems including medication interactions, sexually transmitted infections, pregnancy, and pathologic uterine conditions (polyps, fibroids) 1
• Evaluate for cardiovascular risk factors that would contraindicate combined hormonal contraceptives, including smoking, hypertension, and history of thromboembolism 2
• Consider that at age 41, combined hormonal contraceptives can help manage perimenopausal symptoms while providing contraception 3

Benefits of Seasonale for Heavy and Irregular Bleeding

• Combined hormonal contraceptives like Seasonale are a mainstay for managing heavy menstrual bleeding, providing both contraception and therapeutic benefits 4
• Extended cycle regimens like Seasonale (which provides 84 days of active pills followed by 7 days of placebo) can minimize blood loss in patients with heavy menstrual bleeding 4
• Monophasic pills with 30-35 μg of ethinyl estradiol (like Seasonale) are recommended as initial therapy for heavy menstrual bleeding 4
• Combined hormonal contraceptives offer protection against endometrial cancer, which is particularly important as women approach perimenopause 5

Management of Potential Side Effects

• Bleeding irregularities are common during the first 3-6 months of combined oral contraceptive use and generally not harmful 1
• For persistent breakthrough bleeding beyond 3 months:
  • NSAIDs for 5-7 days during days of bleeding 1
  • Additional low-dose estrogen for 10-20 days if medically eligible 1
• For heavy bleeding on an extended regimen like Seasonale, consider a hormone-free interval of 3-4 consecutive days, but not during the first 21 days of use and not more than once per month 1

Important Considerations and Contraindications

• Combined hormonal contraceptives increase the risk of venous thromboembolism (VTE) three to fourfold (up to 4 per 10,000 woman-years) 4
• Strongly contraindicated in women with positive antiphospholipid antibodies due to increased thromboembolism risk 2
• For women with contraindications to estrogen-containing contraceptives, consider progestin-only options like levonorgestrel IUD or progestin-only pills 2
• If the patient has decompensated liver disease, Seasonale would be unacceptable (CDC MEC category 4) 2

Follow-up Recommendations

• No routine follow-up visit is required, but advise the patient to return if she has concerns about side effects or wants to change methods 1
• At follow-up visits, assess satisfaction with the current method, evaluate any changes in health status that might affect eligibility, and measure blood pressure 1
• If bleeding irregularities persist despite treatment and are unacceptable to the patient, counsel her on alternative contraceptive methods 1

Alternative Options if Seasonale is Contraindicated

• Levonorgestrel IUD is highly effective for heavy menstrual bleeding and provides contraception without estrogen-related risks 2, 4
• Progestin-only pills have a typical failure rate of 6% but avoid estrogen-related risks 2
• For women who have completed childbearing, permanent sterilization could be considered 3