What is the initial approach to managing irregular menses (irregular menstrual cycles)?

Initial Approach to Managing Irregular Menses

The initial approach to managing irregular menses should begin with ruling out underlying gynecological problems including pregnancy, sexually transmitted infections, medication interactions, and pathologic uterine conditions before starting any treatment. 1

Diagnostic Evaluation

• Obtain a detailed history of bleeding patterns, including frequency, duration, and amount of flow 2
• Rule out pregnancy with a pregnancy test in all reproductive-age women with abnormal uterine bleeding 3
• Consider laboratory tests to evaluate for:
  • Polycystic ovary syndrome (PCOS), which affects 10-25% of women with temporal lobe epilepsy and 4-6% of the general population 3
  • Thyroid dysfunction, which can cause menstrual irregularities 1
  • Prolactin levels, especially if amenorrhea is present 3
• Perform a physical examination to assess for signs of:
  • Hyperandrogenism (hirsutism, acne) which may indicate PCOS 3
  • Obesity, which can trigger development of PCOS 3
• Consider pelvic ultrasound if PCOS is suspected, looking for >10 peripheral cysts, 2-8 mm in diameter 3

Laboratory Testing

• For suspected reproductive endocrine disorders, consider the following tests between days 3-6 of the menstrual cycle 3:
  • LH and FSH (LH/FSH ratio >2 suggests PCOS)
  • Prolactin (>20 μg/L is abnormal)
  • Progesterone (mid-luteal phase, <6 nmol/L indicates anovulation)
  • Testosterone (>2.5 nmol/L suggests PCOS)
  • Glucose/insulin ratio (>4 suggests reduced insulin sensitivity)

Treatment Algorithm

For Amenorrhea (Absence of Menses)

• If pregnancy is ruled out and the patient has secondary amenorrhea, progesterone capsules may be given as a single daily dose of 400 mg at bedtime for 10 days 4
• Amenorrhea without other concerns does not always require medical treatment; reassurance may be sufficient 3
• If amenorrhea persists and is unacceptable to the patient, counsel on alternative contraceptive methods 3

For Irregular Bleeding Patterns Without Heavy Bleeding

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 3, 1
  • Mefenamic acid 500 mg three times daily for 5 days 2
  • Celecoxib 200 mg daily for 5 days 2

For Heavy or Prolonged Bleeding

• If medically eligible, consider low-dose combined oral contraceptives for short-term treatment (10-20 days) 3, 1
• For women who cannot use estrogen-containing contraceptives, consider progestin-only options:
  • Levonorgestrel 20 μg/d-releasing intrauterine device, which can reduce menstrual blood loss by 71-95% 3
  • Progestin-only pills, which can be started if >5 days after menses with 2 days of backup contraception 3

Special Considerations

• Adolescents: Irregular menses during the first 3 years after menarche are common but do not exclude disorders requiring diagnosis and treatment 5
• It is abnormal for an adolescent to be amenorrheic for greater than 3 months, even in early gynecologic years 6
• Women with epilepsy have higher rates of PCOS (10-25%) and may require specialized management 3
• Enhanced counseling about expected bleeding patterns can reduce method discontinuation when using hormonal treatments 3

Follow-up Recommendations

• If irregular bleeding persists despite treatment and is unacceptable to the patient, consider alternative methods or referral to a specialist 3
• Schedule appropriate follow-up to monitor response to treatment 2
• For women with PCOS, consider long-term monitoring for metabolic syndrome, as menstrual irregularity has been associated with various diseases including metabolic syndrome and coronary heart disease 7

Important Caveats

• Combined hormonal contraceptives increase the risk of venous thromboembolism three to fourfold 1
• Progesterone capsules may cause drowsiness and dizziness and should be taken at bedtime 4
• Untreated estrogen deficiency due to amenorrhea is a risk factor for later development of osteoporosis 6