What is the best management approach for a female patient of reproductive age with polymenorrhea?

Management of Polymenorrhea

For a reproductive-age woman with polymenorrhea (menstrual cycles <23 days), begin with NSAIDs for 5-7 days during bleeding as first-line treatment, and if ineffective, use low-dose combined oral contraceptives for 10-20 days. 1

Initial Diagnostic Evaluation

Before initiating treatment, you must exclude underlying pathology that could be causing the frequent bleeding:

• Rule out pregnancy first with beta-hCG testing if the patient is sexually active or clinically indicated 1, 2
• Screen for sexually transmitted infections as these can cause irregular bleeding patterns 1
• Assess for structural uterine pathology including polyps and fibroids, which are present in approximately 50% of women with abnormal bleeding 1, 3
• Check thyroid function (TSH, free T4) and prolactin levels as these are the most common endocrine causes of menstrual irregularity 2
• Review medications for potential drug interactions that could affect bleeding patterns 1

When to Perform Imaging

• Transvaginal ultrasound is indicated if clinical features or hormonal tests raise concern about ovarian pathology 4, 2
• Consider transabdominal ultrasound if the patient is not sexually active 2
• Transvaginal ultrasound is more sensitive than transabdominal for identifying structural ovarian abnormalities including tumors and cystic changes 4

Treatment Algorithm

First-Line: NSAIDs

Start with NSAIDs for short-term treatment during days of bleeding (5-7 days), which reduce menstrual blood loss by 20-60% 1, 3

• Mefenamic acid 500 mg three times daily is the specific NSAID recommended during bleeding days 1, 5
• NSAIDs work by reducing prostaglandin levels in the endometrium, which are often abnormally elevated in women with menorrhagia 5

Second-Line: Hormonal Therapy

If NSAIDs are ineffective or contraindicated, use low-dose combined oral contraceptives (30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate) for 10-20 days 1, 2

• Combined oral contraceptives provide cycle regulation and are safe throughout reproductive years 2
• This approach is appropriate for short-term treatment when NSAIDs fail 1

Alternative Hormonal Options

• Tranexamic acid is an antifibrinolytic agent that reduces menstrual blood loss by 20-60% and can be used in isolation or combined with hormonal treatments 3, 6, 5
• Levonorgestrel-releasing intrauterine system (LNG-IUS) is highly effective, with efficacy comparable to endometrial ablation or hysterectomy for long-term management 3, 6

Important Clinical Caveats

What NOT to Do

• Do not use cyclic progestogens for women who ovulate, as they do not significantly reduce menstrual bleeding 3
• Do not assume functional bleeding without excluding structural pathology, especially if bleeding persists 2

Counseling Points

• Bleeding irregularities are generally not harmful but can significantly impact quality of life 1
• Enhanced counseling about expected bleeding patterns reduces discontinuation of hormonal contraceptives 1
• If the woman's regular bleeding pattern changes abruptly to amenorrhea while on treatment, rule out pregnancy 7

When to Refer

Refer to endocrinology or gynecology if:

• Menstrual irregularity persists despite treatment 4
• Hormonal tests reveal persistently abnormal levels 4
• Structural pathology is identified on imaging requiring surgical intervention 1

Surgical Considerations

• Endometrial ablation is a minor surgical procedure with low operative morbidity that can be performed as an outpatient when medical therapies fail 6
• Hysterectomy remains the definitive treatment when medical therapies have failed and endometrial ablation is not suitable 6
• Drug treatment should be used and evaluated before surgical interventions are considered 3