Treatment of Intermittent Menstruation (Irregular Periods)
The first step is to rule out pregnancy, sexually transmitted infections, medication interactions, and structural uterine pathology (polyps, fibroids) before initiating any treatment for irregular menses. 1, 2
Diagnostic Workup
Obtain a pregnancy test (beta-hCG) in all reproductive-age women with irregular bleeding as the initial step. 2 This is non-negotiable regardless of patient history.
Essential Laboratory Tests
Perform the following tests between days 3-6 of the menstrual cycle: 1
- LH and FSH levels (LH/FSH ratio >2 suggests PCOS) 1
- Prolactin (>20 μg/L is abnormal and indicates hyperprolactinemia) 1
- TSH (thyroid dysfunction commonly causes ovulatory dysfunction) 2
- Testosterone (>2.5 nmol/L suggests PCOS) 1
- Mid-luteal progesterone (<6 nmol/L indicates anovulation) 1
Imaging Studies
Perform transvaginal ultrasonography or saline infusion sonohysterography to evaluate for endometrial polyps, submucosal fibroids, adenomyosis, or malignancy, especially in women age 35 and older where structural pathology becomes more common. 2
Treatment Algorithm Based on Bleeding Pattern
For Irregular Spotting or Light Bleeding (First-Line)
Use NSAIDs as first-line treatment during bleeding episodes: 1, 2
- Mefenamic acid 500 mg three times daily for 5-7 days (reduces menstrual blood loss by 20-60%) 3, 2
- Alternative: Celecoxib 200 mg daily for 5 days 1
- Alternative: Naproxen 440-550 mg every 12 hours with food 2
- Alternative: Ibuprofen 600-800 mg every 6-8 hours with food 2
Critical pitfall: Never use aspirin for bleeding treatment as it may worsen bleeding. 2
For Heavy or Prolonged Bleeding (Second-Line)
If NSAIDs are insufficient and the patient is medically eligible, use low-dose combined oral contraceptives for short-term treatment (10-20 days). 3, 1 This approach is supported by CDC guidelines showing that combined hormonal contraceptives can regulate menstrual cycles and reduce bleeding. 2
Important caveat: Combined hormonal contraceptives increase the risk of venous thromboembolism three to fourfold. 1 Screen for contraindications including history of blood clots, stroke, or heart attack before prescribing.
For Women Who Cannot Use Estrogen
Consider the levonorgestrel-releasing intrauterine system (LNG-IUS), which reduces menstrual blood loss by 71-95% and is the most effective medical treatment for menorrhagia. 2
Counsel patients to expect irregular spotting during the first 3-6 months of LNG-IUS use. 2 Enhanced counseling about expected bleeding patterns significantly reduces treatment discontinuation rates. 3, 1
Treatment for Secondary Amenorrhea
If the diagnosis is secondary amenorrhea due to progesterone deficiency (confirmed by mid-luteal progesterone <6 nmol/L), prescribe progesterone capsules 400 mg as a single daily dose at bedtime for 10 days. 4
Critical warning: Progesterone capsules contain peanut oil and should not be used if the patient is allergic to peanuts. 4 Some women experience drowsiness, dizziness, blurred vision, difficulty speaking, or difficulty walking after taking progesterone capsules; advise bedtime dosing. 4
When to Refer
Refer to gynecology or endocrinology if: 5
- Hormonal workup reveals complex endocrine abnormalities 5
- Structural pathology is identified on imaging 2
- Irregular bleeding persists despite treatment and is unacceptable to the patient 3, 1
- Infertility is a concern (inability to conceive after 12 months of unprotected intercourse) 5
Follow-Up Monitoring
Monitor response to symptomatic bleeding management within 1-2 menstrual cycles. 5 If irregular bleeding persists and the patient finds it unacceptable, assist with choosing another contraceptive method or refer to a specialist. 3
Special Populations
Women with epilepsy have higher rates of PCOS (10-25% versus 4-6% in the general population) and may require specialized management. 1 Certain antiepileptic drugs can affect reproductive hormones and should be considered when evaluating irregular menses. 5