What is the appropriate workup for an 18-year-old female (18F) on Slynd (drospirenone and ethinyl estradiol) who has experienced amenorrhea (absence of menstruation) for a few months?

From the Guidelines

For an 18-year-old female on Slynd (drospirenone 4 mg) who has not had a period in a few months, the initial workup should include a pregnancy test, even though Slynd is a contraceptive, as recommended by the U.S. selected practice recommendations for contraceptive use, 2013 1. The initial step in evaluating amenorrhea in this patient is to rule out pregnancy, as it is a common cause of amenorrhea.

Initial Workup

• Pregnancy test: to rule out pregnancy as a cause of amenorrhea
• Basic laboratory tests:
  • Complete blood count to assess for anemia
  • Thyroid function tests (TSH, free T4) to rule out thyroid disorders
  • Prolactin levels to check for hyperprolactinemia

Additional Testing

• Consider testing for follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to evaluate ovarian function, as recommended by the IOC consensus statement on relative energy deficiency in sport (RED-S) 1
• If the patient is experiencing other symptoms like hirsutism or acne, additional testing for androgens and consideration of conditions like polycystic ovary syndrome may be warranted

Clinical Evaluation

• A detailed menstrual history, sexual history, and review of other medications should also be obtained
• If all tests are normal and the amenorrhea is determined to be due to Slynd, no intervention is typically needed unless the patient is concerned about the lack of periods, as amenorrhea does not require any medical treatment and reassurance can be provided, according to the U.S. selected practice recommendations for contraceptive use, 2013 1.

From the FDA Drug Label

Although the occurrence of pregnancy is low if drospirenone and ethinyl estradiol tablets are taken according to directions, if withdrawal bleeding does not occur, consider the possibility of pregnancy If the patient has adhered to the prescribed regimen and misses two consecutive periods, rule out pregnancy

If a patient on Slynd (drospirenone and ethinyl estradiol tablets) has not had a period in a few months, the following workup needs to be done:

• Rule out pregnancy: This is the first step, as the absence of withdrawal bleeding could indicate pregnancy.
• Check adherence to the prescribed regimen: Verify that the patient has been taking the tablets as directed. The following lab should be checked:
• Pregnancy test: To confirm or rule out pregnancy. 2