What are the medical management options for irregular periods?

Medical Management of Irregular Periods

For women with irregular periods not using contraception, combined oral contraceptives are the first-line treatment to regulate menstrual cycles, with metformin as an alternative for those who cannot take hormonal contraception or are attempting conception. 1

Initial Evaluation

Before initiating treatment, rule out underlying causes that require specific management:

• Pregnancy testing is mandatory in all women of reproductive age with menstrual irregularities 2
• Measure serum FSH, LH, prolactin, and TSH to identify hormonal disorders 3, 2
• Assess for polycystic ovary syndrome (PCOS), which affects 4-6% of women and is the most common cause of irregular periods 3, 1
  • Check testosterone (abnormal if >2.5 nmol/l), LH/FSH ratio (abnormal if >2), and mid-luteal progesterone (<6 nmol/l indicates anovulation) 3
  • Consider pelvic ultrasound showing >10 peripheral cysts (2-8 mm diameter) 3
• Rule out thyroid disorders, hyperprolactinemia, and anatomic abnormalities (fibroids, polyps) before starting treatment 2, 4

First-Line Treatment Options

For Women NOT Seeking Pregnancy

Combined low-dose hormonal contraceptives are the most effective first-line choice for regulating menstrual cycles 1:

• These provide the critical added benefit of reducing endometrial hyperplasia and cancer risk in anovulatory women 1
• Progestin-only options are alternatives for women with contraindications to estrogen 1

For Women Seeking Pregnancy or With Contraindications to Hormones

Metformin is the appropriate medical option to improve ovulation rates 1:

• Particularly effective in PCOS patients attempting conception 1
• Clomiphene citrate is FDA-approved for ovulatory dysfunction in women desiring pregnancy, especially those with PCOS 5
• Start clomiphene on day 5 of the cycle; limit to 6 total cycles (including 3 ovulatory cycles) 5

Management of Heavy or Prolonged Bleeding

If irregular periods include heavy menstrual bleeding:

NSAIDs for 5-7 days during bleeding are first-line treatment 6, 4:

• Mefenamic acid (500 mg three times daily for 5 days) or celecoxib (200 mg daily for 5 days) significantly reduce bleeding 7, 6
• Multiple NSAIDs (indomethacin, flufenamic acid, diclofenac) demonstrate statistically significant reductions in menstrual blood loss 3, 6
• Avoid aspirin, which may increase blood loss in some women 6

Tranexamic acid can significantly reduce menstrual blood loss but is contraindicated in women with thromboembolic disease or thrombosis risk 3, 6

Levonorgestrel-releasing IUD (LNG-IUD) is the most effective long-term approach, reducing menstrual blood loss by 71-95% 6

Lifestyle Modifications

For overweight or obese women with PCOS, dietary and lifestyle modifications should be the first-line intervention before medical therapy 1:

• Weight loss can restore ovulation and regular cycles 3, 1
• Address the underlying insulin resistance and metabolic dysregulation 3

Important Caveats

• Women with cardiovascular disease should avoid tranexamic acid and NSAIDs due to increased thrombosis and MI risk 6
• Evaluate for endometrial cancer risk in women with chronic anovulation, especially those over 35 years 5, 2
• Screen PCOS patients for metabolic syndrome, type 2 diabetes, and cardiovascular disease risk 2
• Certain antiepileptic drugs (valproate, carbamazepine, phenytoin) can worsen menstrual irregularities and should be considered in the medication history 3