What are the hormonal treatment options for irregular (wavy) menstrual bleeding in a reproductive‑age woman?

Hormonal Treatment of Irregular Menstrual Bleeding

For irregular menstrual bleeding in reproductive-age women, combined oral contraceptives (COCs) or progestin-only contraceptives are the primary hormonal treatment options, with low-dose COCs or estrogen used for 10-20 days during bleeding episodes if an underlying gynecologic problem has been excluded. 1

Initial Evaluation Before Treatment

Before initiating hormonal therapy, systematically exclude:

• Pregnancy (always rule out first) 1, 2
• Sexually transmitted infections 1, 2
• Medication interactions 1, 2
• New pathologic uterine conditions (fibroids, polyps, malignancy) 1

If any underlying gynecologic problem is identified, treat that condition or refer for specialized care rather than treating the bleeding symptomatically 1.

Hormonal Treatment Options by Clinical Scenario

For Heavy or Prolonged Irregular Bleeding

First-line hormonal treatment:

• Low-dose combined oral contraceptives (COCs) for 10-20 days during active bleeding episodes 1
• Estrogen alone for 10-20 days during active bleeding episodes (if medically eligible) 1

These short-term hormonal treatments are used specifically during days of bleeding, not as continuous therapy 1.

For Ongoing Management and Prevention

Combined hormonal contraceptives (if medically eligible):

• Combined oral contraceptives (various formulations) 1
• Transdermal contraceptive patch (releases 150 μg norelgestromin and 20 μg ethinyl estradiol daily) 1
• Vaginal contraceptive ring (releases 120 μg etonogestrel and 15 μg ethinyl estradiol daily) 1

Combined hormonal contraceptives induce regular shedding of a thinner endometrium and inhibit ovulation, providing both bleeding control and contraception 3.

Progestin-only options:

• Progestin-only contraception is recommended by ACOG for abnormal uterine bleeding associated with ovulatory dysfunction 1
• Long-course oral progestogens (≥3 weeks per cycle) reduce menstrual blood loss by approximately 87% 1, 4
• Levonorgestrel-releasing intrauterine system (LNG-IUS) releasing 20 μg/day is the most effective hormonal option, reducing menstrual blood loss by 71-95% and is comparable to endometrial ablation 1, 4

Treatment Algorithm

1. Rule out pregnancy and pathology first 1, 2
2. For acute heavy/prolonged bleeding: Use low-dose COCs or estrogen for 10-20 days during bleeding 1
3. For ongoing irregular bleeding: Initiate combined hormonal contraceptives (pills, patch, or ring) or progestin-only methods 1
4. If bleeding persists despite treatment: Counsel on alternative contraceptive methods and offer to switch 1

Medical Eligibility Considerations

Verify no contraindications to estrogen-containing contraceptives:

• Severe uncontrolled hypertension 2
• Migraines with aura 2
• History of thromboembolism or thrombophilia 2
• Active liver disease 2
• Complicated valvular heart disease 2

For women with cardiovascular disease history (such as spontaneous coronary artery dissection), hormonal therapy is relatively contraindicated and requires careful clinical judgment 1.

Expected Outcomes and Counseling

Bleeding patterns with combined hormonal contraceptives:

• Unscheduled spotting or bleeding is common during the first 3-6 months of use 1, 5
• These irregularities are generally not harmful and typically improve with persistent use 1
• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1, 2

When to consider changing methods:

• If bleeding persists and the woman finds it unacceptable after appropriate treatment 1
• Consider switching to a different combined hormonal contraceptive formulation 6, 7
• Consider the LNG-IUS as it is more effective than COCs for reducing menstrual blood loss 3

Important Caveats

Do not:

• Change to a higher estrogen content contraceptive unnecessarily, as this increases thromboembolic risk 6, 7
• Continue the same regimen indefinitely if bleeding persists beyond initial management 5
• Overlook that changing preparations may solve the problem if time alone does not 6, 7

Comparative effectiveness (in descending order for reducing menstrual blood loss):

1. LNG-IUS (20 μg/day) 4
2. Combined hormonal contraceptives 4
3. Long-course oral progestogens (≥3 weeks per cycle) 4

The LNG-IUS is considered first-line medical therapy for heavy menstrual bleeding in women not seeking pregnancy, with combined hormonal contraceptives as second choice 4, 8.