What can be given to a patient to induce a menstrual period if she refuses to stop growth hormone (GH) therapy?

Inducing Menstruation in a Patient Continuing Growth Hormone Therapy

Progesterone therapy is the recommended approach to induce menstruation in a patient who refuses to stop growth hormone therapy. 1

First-Line Treatment Options

• For patients requiring menstrual induction while continuing growth hormone therapy, oral progesterone can be administered as a single daily dose of 400 mg at bedtime for 10 days to induce withdrawal bleeding 1
• Most women (approximately 80%) will experience withdrawal bleeding within 7 days of the last dose of progesterone 1
• Progesterone capsules should be taken at bedtime as some women may experience drowsiness or dizziness after administration 1

Medication Selection and Administration

• Micronized progesterone is preferred over synthetic progestins due to its more favorable side effect profile 2
• Be aware that micronized progesterone capsules contain peanut oil and are contraindicated in patients with severe peanut allergies 3, 1
• For secondary amenorrhea, the standard dosing regimen is 400 mg daily at bedtime for 10 days 1
• If the patient has difficulty swallowing progesterone capsules, advise taking the dose while standing with a full glass of water 1

Monitoring and Follow-Up

• Schedule follow-up within 2 weeks after completing the progesterone course to confirm whether withdrawal bleeding has occurred 2
• Monitor for common side effects including drowsiness, dizziness, and in rare cases, blurred vision or difficulty speaking 1
• Consider measuring serum IGF-1 levels to determine if growth hormone therapy is causing supraphysiological effects that could be interfering with normal menstrual function 4

Alternative Options

• If oral progesterone is not tolerated or contraindicated, medroxyprogesterone acetate 10 mg daily for 10 days can be used as an alternative 2
• For patients who also require contraception, combined oral contraceptives containing 17β-estradiol would be preferable over ethinylestradiol-based formulations 2
• Transdermal estrogen with cyclic oral progesterone can be considered if oral medications are not tolerated 2

Long-Term Considerations

• While inducing menstruation is possible with progesterone therapy, the patient should be informed that continuing growth hormone may lead to persistent menstrual irregularities 4
• Consider discussing dose reduction of growth hormone if menstrual irregularities persist despite progesterone therapy 4
• Be aware that growth hormone therapy should ideally be discontinued when height velocity drops below 2 cm per year or when epiphyseal growth plate closure is evident 4

Cautions and Contraindications

• Progesterone therapy is contraindicated in patients with:

  • Severe peanut allergies (due to peanut oil in the formulation) 3, 1
  • Hormone receptor-positive cancers 3
  • Undiagnosed vaginal bleeding 1
  • History of thromboembolism or liver disease 1

• Monitor for potential interactions between growth hormone and progesterone, although significant interactions are not well-documented 5, 6

By following this approach, you can effectively induce menstruation in your patient while allowing them to continue growth hormone therapy, though the ideal solution would still be to discontinue growth hormone if clinically appropriate.