eMedicine Specialties > Pediatrics: Surgery > Gynecology
Menstruation Disorders: Treatment & Medication
Updated: Jun 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Amenorrhea
- Treatment depends on etiology. Direct therapy to the underlying cause.
- If the patient has a completely normal physical examination with secondary amenorrhea, consider administering medroxyprogesterone 10 mg daily for 5-10 days to see if withdrawal bleeding occurs. If this occurs, adequate levels of endogenous estrogen and normal anatomy are indicated.
- Dysmenorrhea
- Provide symptomatic relief with nonsteroidal anti-inflammatory drugs (eg, naproxen, ibuprofen) at the first sign of cramps.
- If nonsteroidal anti-inflammatory therapy fails, consider oral contraceptive pills for 3-6 months. If this fails as well, look for secondary causes of dysmenorrhea.
- Short-term use of selective estrogen receptor modulators (SERMs), such as tamoxifen, in selected refractory cases has produced good results.
- Menorrhagia
- Most cases of menorrhagia fall under the category of DUB. In situations in which a specific etiology is identified, treatment of the underlying cause is necessary.
- For patients with mild DUB, provide reassurance and observation. Instruct the patient to keep a menstrual calendar. Consider iron supplementation and antiprostaglandin medications during bleeding episodes.
- For patients with moderate DUB, prescribe combination oral contraceptive pills beginning with 4 monophasic 35-microgram pills a day and tapering down. Oral contraceptive pills are usually continued for 6 months. Medroxyprogesterone alone may also be used. Also administer oral iron and folic acid supplements.
- If DUB is severe, consider an undiagnosed underlying disorder, such as von Willebrand disease or factor VII deficiency. For patients with severe DUB, consider hospitalization and coagulation studies. Administer intravenous Premarin every 4 hours until the bleeding stops, up to 4 doses. Simultaneously administer a monophasic 35-microgram oral contraceptive pill every 6 hours for 24-48 hours and then twice daily to complete a 28-day course. If Premarin does not stop the bleeding after 4 doses, consider pelvic pathology. Examination under anesthesia and dilatation and curettage may be necessary.
- An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Willebrand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.3 Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis of these disorders in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. If a bleeding disorder is suspected, consultation with a hematologist is suggested. An underlying bleeding disorder should be considered when a patient has any of the following:
- Menorrhagia since menarche
- Family history of bleeding disorders
- Personal history of one or more of the following: (1) notable bruising without known injury, (2) bleeding of oral cavity or GI tract without obvious lesion, or (3) epistaxis that persists more than 10 minutes (possibly necessitating packing or cautery)
- Recent literature (including information from the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice) favors the use of levonorgestrel intrauterine devices (eg, Progestasert, Mirena coil) as safe and effective treatment for severe menorrhagia.4 The quality of life among patients receiving this treatment was comparable to those receiving surgical treatments.
Surgical Care
- Surgical options for the management of severe menorrhagia include thermal balloon endometrial ablation, transcervical resection of the endometrium (TCRE), and hysterectomy.5
Medication
Medications used in the management of menstrual disorders depend on the type of disorder and the etiology of the disorder.
Hormones
In patients with secondary amenorrhea who have a completely normal physical examination, medroxyprogesterone can be used to diagnose anovulation as the cause of amenorrhea (progesterone challenge test). Estrogens are effective in controlling acute, profuse bleeding. Estrogen also induces formation of progesterone receptors, making subsequent treatment with progestins more effective.
Medroxyprogesterone (Provera, Cycrin)
Short-acting synthetic progestin. Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until maturity of positive feedback system is achieved. Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal. Typically does not stop acute bleeding episode but produces a normal bleeding episode following withdrawal.
Adult
10 mg PO qd for 5-10 d
Pediatric
Adolescents: Administer as in adults
Aminoglutethimide increases hepatic metabolism of medroxyprogesterone
Documented hypersensitivity; cerebral apoplexy, undiagnosed vaginal bleeding, thrombophlebitis, and liver dysfunction
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders
Ethinyl estradiol and a progestin derivative (Ovral, Ortho-Novum, Ovcon, Genora)
Combination pills of estrogen and progesterone in varying doses are used in the management of DUB. 21-day or 28-day cycles are used. Reduces secretion of LH and FSH from pituitary by decreasing amount of GnRH
Adult
Dysmenorrhea:
21-day cycle: 1 tab PO qd for 21 d, do not take tablets for 7 d then resume
28-day cycle: 1 tab PO qd; last 7 tabs in cycle are placebo to help maintain compliance
Menorrhagia, moderate: Initiate with 4 monophasic 35-mcg tab PO qid on day 1, then taper downward
Pediatric
Adolescents: Administer as in adults
May reduce hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and pregnancy; increase in fluid retention caused by estrogen intake may reduce seizure control
Documented hypersensitivity; thrombophlebitis, undiagnosed vaginal bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Exercise caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Conjugated equine estrogen (Premarin)
Induces the synthesis of DNA, RNA, and various proteins in target tissues. Reduces the secretion of LH and FSH from the pituitary by decreasing amount of GnRH.
Adult
Severe DUB: 25 mg IV q4h until bleeding stops, up to 4 doses; concurrently administer 35-mcg oral combination contraceptive pill PO q6h for 24-48 h, then bid to complete a 28-day cycle
Pediatric
Not established
May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins
Documented hypersensitivity; known or suspected pregnancy; breast cancer, undiagnosed abnormal genital bleeding, active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, such as, abnormal or excessive uterine bleeding or mastodynia; estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents block formation of prostacyclin, an antagonist of thromboxane, which is a substance that accelerates platelet aggregation and initiates coagulation.
Naproxen (Aleve, Anaprox, Naprosyn)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO once, after 6 h initiate 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
Adolescents: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Mineral supplementation
These agents are used to provide adequate iron for hemoglobin synthesis and to replenish body stores.
Iron sulfate (Feosol, Feratab, Fer-Iron, Slow-FE)
A nutritionally essential inorganic substance.
Adult
325 mg PO qd
Pediatric
Adolescents: Administer as in adults
Absorption is enhanced by ascorbic acid; interferes with tetracycline absorption; food and antacids impair absorption
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
GI upset; iron toxicity is observed with ingestion of large amount and can be fatal especially in children; parenteral (IV) administration may cause several reactions, including headaches, malaise, fever, generalized lymphadenopathy, arthralgia, and urticaria; can cause severe anaphylaxis; others include phlebitis at infusion site
More on Menstruation Disorders |
| Overview: Menstruation Disorders |
| Differential Diagnoses & Workup: Menstruation Disorders |
 Treatment & Medication: Menstruation Disorders |
| Follow-up: Menstruation Disorders |
| References |
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References
Cosgrove L, Riddle B. Constructions of femininity and experiences of menstrual distress. Women Health. 2003;38(3):37-58. [Medline].
Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. Dec 2006;19(6):363-71. [Medline].
James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, et al. Von Willebrand disease and other bleeding disorders in women: Consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. May 28 2009;[Medline].
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG committee opinion. No. 337: Noncontraceptive uses of the levonorgestrel intrauterine system. Obstet Gynecol. Jun 2006;107(6):1479-82. [Medline].
[Best Evidence] Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855. [Medline].
Braverman PK, Sondheimer SJ. Menstrual disorders. Pediatr Rev. Jan 1997;18(1):17-25; quiz 26. [Medline].
Emans JS, Laufer M, Goldstein DP. Delayed puberty and menstrual irregularities. In: Pediatric and Adolescent Gynecology. 4th ed. 1998:163-261.
Gordon CM. Menstrual disorders in adolescents. Excess androgens and the polycystic ovary syndrome. Pediatr Clin North Am. Jun 1999;46(3):519-43. [Medline].
Harlow SD, Campbell OM. Epidemiology of menstrual disorders in developing countries: a systematic review. BJOG. Jan 2004;111(1):6-16. [Medline].
Iglesias EA, Coupey SM. Menstrual cycle abnormalities: diagnosis and management. Adolesc Med. Jun 1999;10(2):255-73. [Medline].
Mitan LA, Slap GB. Adolescent menstrual disorders. Update. Med Clin North Am. Jul 2000;84(4):851-68. [Medline].
Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol. Feb 2003;17(1):75-92. [Medline].
Further Reading
Keywords
menstruation disorders, irregularities of menstruation, menstrual disorders, amenorrhea, oligomenorrhea, dysmenorrhea, secondary dysmenorrhea, painful menstruation, menorrhagia, anovulatory cycles, irregular menstrual patterns, thelarche, menarche, dysfunctional uterine bleeding, DUB, menstruation disorders, hypothalamic-pituitary-ovarian axis, HPO axis, endometriosis, pelvic inflammatory disease, uterine fibroids, Crohn disease, constitutional delay of puberty, hypothalamic dysfunction, pituitary failure, gonadal failure, Turner Syndrome, Swyer syndrome, gonadotrophin deficiency, Kallmann syndrome, hyperandrogenic amenorrhea, hypothalamic amenorrhea, hypothyroidism, hyperprolactinemia, outflow tract obstructions, imperforate hymen, vaginal atresia, Müllerian agenesis, androgen insensitivity
