What are the next steps for managing interstitial cystitis symptoms that worsen around the menstrual cycle?

Management of Menstrual-Related Interstitial Cystitis Flares

This patient requires gynecologic evaluation to assess for hormonal influences on IC/BPS symptoms, with consideration of hormonal therapy if endometriosis or hormonal cyclicity is confirmed, while simultaneously optimizing IC/BPS-specific treatments. 1, 2

Immediate Next Steps

Gynecologic Evaluation

• Schedule gynecologic consultation to evaluate for endometriosis and hormonal contributions to pelvic pain. 1 IC/BPS commonly coexists with endometriosis as part of the "Evil Twins" syndrome, where both conditions share overlapping pathophysiology and frequently occur together. 1

• Document the precise timing of symptom worsening relative to the menstrual cycle (follicular vs. luteal phase, during menses, or perimenstrually). 1

• Consider pelvic ultrasound to evaluate for ovarian cysts or endometriomas if not recently performed. 1

Reassess Current IC/BPS Treatment Status

• Determine which IC/BPS treatments have already been tried and their effectiveness. 1, 2

• If the patient is not currently on treatment or only on first-line behavioral modifications, escalate therapy according to the systematic approach below. 2

Systematic Treatment Escalation for IC/BPS

First-Line: Behavioral Modifications (if not already optimized)

• Implement an elimination diet to identify trigger foods, particularly coffee, citrus, and spicy foods. 2

• Apply local heat over the bladder or perineum during flares for symptomatic relief. 2

• Practice pelvic floor muscle relaxation exercises only—never strengthening exercises, which worsen IC/BPS symptoms. 2

Second-Line: Oral Medications

• Start amitriptyline 10 mg daily at bedtime, titrating up to 100 mg as tolerated. 2 This has Grade B evidence showing superiority to placebo and is recommended by the American College of Physicians. 2

• Common side effects include sedation and drowsiness, which may be beneficial if taken at bedtime. 2

• Alternatively, consider pentosan polysulfate sodium 100 mg three times daily (the only FDA-approved oral medication for IC/BPS), but mandatory ophthalmologic monitoring is required due to risk of macular damage. 2

Second-Line: Intravesical Therapies

• Heparin instillations repair the damaged glycosaminoglycan layer and provide clinically significant symptom improvement. 2

• Lidocaine instillations provide rapid temporary relief of bladder pain. 2

Hormonal Considerations for Menstrual-Related Symptoms

If Endometriosis is Confirmed

• Coordinate with gynecology for hormonal suppression therapy (continuous oral contraceptives, GnRH agonists, or progestins) to reduce cyclical pelvic pain. 1

• Recognize that treating endometriosis alone may not fully resolve IC/BPS symptoms, as both conditions require concurrent management. 1

If No Endometriosis but Clear Hormonal Pattern

• Consider trial of continuous oral contraceptives to eliminate menstrual cycling and assess symptom response. 1

• Document symptom changes with hormonal manipulation to guide ongoing management. 1

Pain Management Throughout Treatment Course

• Initiate multimodal pain management with non-opioid alternatives preferred due to the chronic nature of IC/BPS. 2

• Pain management alone is insufficient—underlying bladder symptoms must be addressed simultaneously. 2

Critical Pitfalls to Avoid

• Do not prescribe antibiotics—long-term antibiotics have no benefit over placebo in IC/BPS and risk antibiotic resistance. 2

• Never recommend pelvic floor strengthening exercises—only relaxation techniques should be used, as strengthening worsens symptoms. 2

• Do not dismiss the menstrual relationship as coincidental—IC/BPS exists as part of a broader systemic hypersensitivity syndrome affecting multiple organs, and hormonal influences are legitimate. 3

• Educate the patient that IC/BPS is a chronic condition with flares and remissions requiring long-term management, and treatment efficacy is unpredictable—multiple therapeutic options may need to be tried. 2

Follow-Up Plan

• Reassess symptoms in 4-6 weeks after initiating or escalating IC/BPS treatment. 2

• Coordinate care between urology/primary care and gynecology to address both IC/BPS and hormonal contributions. 1

• Document baseline symptoms using validated tools such as the Interstitial Cystitis Symptom Index (ICSI) to track treatment response. 2