What hormonal treatments can be used to stop menstruation in a female patient of reproductive age?

Hormonal Treatments to Stop Menstruation

The levonorgestrel-releasing intrauterine device (LNG-IUS) is the single most effective hormonal option for menstrual suppression, achieving 71-95% reduction in menstrual blood loss with 22% of users experiencing complete amenorrhea. 1

First-Line Hormonal Options

Levonorgestrel-Releasing Intrauterine Device (LNG-IUS)

• Most effective long-term option for menstrual suppression, particularly useful when estrogen is contraindicated 1
• Achieves 71-95% reduction in menstrual blood loss with 22% of users reaching complete amenorrhea 1
• Superior to combined oral contraceptives for reducing menstrual blood loss (OR 0.21,95% CI 0.09 to 0.48) 2
• Irregular bleeding is common initially but improves with continued use 1

Depot Medroxyprogesterone Acetate (DMPA)

• Highly effective for long-term suppression when administered as 150 mg intramuscularly or 104 mg subcutaneously every 13 weeks 1
• Nearly all patients experience menstrual irregularities initially, which improve over time and often result in amenorrhea 1
• Amenorrhea becomes increasingly common with continued use 3
• Available in two formulations (150 mg IM or 104 mg SC) with the only difference being route of administration 4

Combined Oral Contraceptives (COCs)

• Can be used continuously (skipping placebo pills) to suppress menses 1
• Less effective than norethindrone for short-term menstrual delay when started late in the cycle 1
• Step-down estrogen and step-up progestogen regimens increase chance of treatment success from 3% (placebo) to 12-77% 2
• Reduce menstrual blood loss significantly (OR 5.15,95% CI 3.16 to 8.40) compared to placebo 2

Cyclic Oral Progestins

• Reduce menstrual bleeding by 87% and typically result in eventual reduction to light bleeding only 1
• Note: Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate 5

Alternative Delivery Methods

Contraceptive Vaginal Ring (CVR)

• Similar efficacy to combined oral contraceptives for menstrual suppression 2
• May provide similar benefits while lessening systemic hormonal exposure 2
• Greater likelihood of nausea with COCP compared to CVR 2

Etonogestrel Implant

• 22% of users experience amenorrhea and 34% experience infrequent spotting 4
• 7% report frequent bleeding and 18% report prolonged bleeding 4
• Unscheduled bleeding or amenorrhea is generally not harmful 4

Clinical Implementation Algorithm

Step 1: Rule Out Pregnancy

• Always rule out pregnancy before initiating any hormonal therapy 1
• Use CDC criteria to be reasonably certain patient is not pregnant 4

Step 2: Assess Contraindications

• In women with spontaneous coronary artery dissection, hormonal therapy including progesterone is relatively contraindicated 1
• Hormone replacement therapy should not be used for secondary prevention in women with established coronary artery disease 1
• Assess for conditions that may be influenced by fluid retention (epilepsy, migraine, asthma, cardiac or renal dysfunction) 6

Step 3: Select Initial Method Based on Patient Factors

For long-term suppression with highest efficacy:

• Choose LNG-IUS as first-line, especially when estrogen is contraindicated 1

For patients preferring injectable method:

• Choose DMPA 150 mg IM or 104 mg SC every 13 weeks 1

For patients preferring oral method:

• Choose continuous combined oral contraceptives (skipping placebo pills) 1, 7
• Alternatively, use cyclic oral progestins 1

Step 4: Manage Breakthrough Bleeding

For DMPA users with unscheduled bleeding:

• First, rule out underlying gynecological problems including medication interactions, STDs, pregnancy, or pathologic uterine conditions (polyps, fibroids) 3
• For unscheduled spotting or light bleeding: NSAIDs for 5-7 days during active bleeding episodes 3
• For heavy or prolonged bleeding: NSAIDs remain first-line (5-7 days); if inadequate, use low-dose COCs or estrogen for 10-20 days if medically eligible 3
• If bleeding persists despite treatment and is unacceptable to patient, counsel on alternative methods (IUDs or implants) 3

For implant users with irregular bleeding:

• Celecoxib 200 mg daily for 5 days or mefenamic acid 500 mg three times daily for 5 days can achieve bleeding cessation within 7 days 4
• Estrogen, daily COCs, or tranexamic acid can reduce bleeding days during treatment 4

For COC users with breakthrough bleeding:

• Rule out underlying gynecological problems, medication interactions, STDs, pregnancy, or new pathologic uterine conditions 4
• If no underlying problem found: NSAIDs for 5-7 days or hormonal treatment with low-dose COCs or estrogen for 10-20 days 4

Essential Patient Counseling

Before Initiating Treatment

• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1, 3
• Discuss that amenorrhea and unscheduled spotting are common, generally not harmful, and will likely decrease with continued use 3
• With DMPA: nearly all patients experience menstrual irregularities initially which improve over time 1
• With LNG-IUS: irregular bleeding is common initially but 22% achieve complete amenorrhea 1
• With implants: 22% experience amenorrhea, 34% infrequent spotting, but 7% have frequent bleeding and 18% prolonged bleeding 4

Realistic Expectations

• Complete amenorrhea may be difficult to achieve 8
• Counsel patients and caregivers about realistic expectations regarding menstrual suppression 8
• Amenorrhea during hormonal contraceptive use is generally not harmful and does not require medical treatment 4, 7

Important Caveats

• Cessation of menses alone is not an adequate indicator of ovarian suppression 4
• Menstrual cycles do not indicate fertility; many patients erroneously assume this 4
• Patients should be alert to physiologic changes suggesting recovery of ovarian function, including resumption of menses or cyclical fluctuations in climacteric symptoms 4

Common Pitfalls to Avoid

• Do not assume cyclic progestogens work for ovulating women - they do not significantly reduce menstrual bleeding in women who ovulate 5
• Do not ignore breakthrough bleeding - always rule out pregnancy, medication interactions, STDs, or pathologic uterine conditions before treating symptomatically 4, 3
• Do not use aspirin for bleeding management - it does not result in significant differences in bleeding episodes 4
• Do not assume amenorrhea requires treatment - provide reassurance that it is generally not harmful 4, 7
• Do not change to higher estrogen content unnecessarily - while potentially useful for minimizing menstrual irregularity, this may increase risk of thromboembolic disease 9