Adolescent Menstrual Disorders: Elimination of Monthly Menstruation and Associated Problems Patricia J. Sulak, M.D. Professor, Texas A&M College of Medicine Director, Scott and White Sex Education Program Medical Director, Division of Research Department of Obstetrics and Gynecology Scott and White Clinic/Hospital, Temple, Texas

Adolescent Hormone Related Disorders

Why Eliminate Monthly Menstruation??

Changes in Reproductive Patterns Past

• • • • • •

Irregular menstrual bleeding Menorrhagia Dysmenorrhea Premenstrual symptoms Facial acne Menstrual associated headaches

Incessant Ovulation / Bleeding: Associated Health Risks • • • • •

Anemia Endometriosis: pain, infertility Ovarian cysts Ovarian cancer PMS / PMDD

VS

Current

• Late menarche

• Early menarche

• Early childbearing

• Late childbearing

• High parity

• Low parity

• Prolonged breastfeeding

• Shortened/absent breastfeeding

• Early death

• Increased longevity

Hormonal therapies, usually birth control pills, are often used to treat menstrual disorders.

21/7 Day Hormonal Contraception: Oral contraceptives, transdermal patch, and vaginal ring

Hormone Withdrawal Symptoms in Oral Contraceptive Users 21 active

7 hormone free

p value

Pelvic pain

21%

70%

7 days of BTB and / or BTS while extending, randomized to: – Taking a 3 day hormone free interval (HFI) or – Continuing extended regimen • Minimum of 21 days of consecutive pills before another 3 day HFI could be instituted.

Sulak et al Am J Obstet Gynecol 2006; 195: 935 - 41

How Do You Manage the Breakthrough Bleeding / Spotting?

BTB / BTS Randomization Protocol • Randomization to a 3 day HFI resulted in an initial increase in flow usually followed by cessation of flow in a few days. • Randomization to continuing active pills usually resulted in continued flow with a greater tendency to require a 3 day HFI. Sulak et al Am J Obstet Gynecol 2006; 195: 935 - 41

Progestin Only Continuous Contraception • Progestin only pills Contraindications to estrogen use Breastfeeding

• Depomedroxyprogesterone acetate • Levonorgestrel intrauterine device • Subdermal implant

So, when is menstruation necessary?

Women must understand the difference between natural ovulatory menstruation and artificially induced “pill periods.” They need to know when it is necessary to menstruate and, importantly, when it is not necessary.

Monthly Menstruation in Reproductive Age Women is Necessary, Unless…. • Pregnant • Using oral contraceptives or other estrogen/progestin contraceptives/ hormones • Using progestin only hormones (LNG IUS, implant, depomedroxyprogesteone, etc) • Breastfeeding • Hysterectomy / Endometrial ablation procedure

Conditions Associated with Oligomenorrhea / Amenorrhea:

• Perimenarcheal • Perimenopausal • Premature ovarian failure • PCOD • Endocrine disorders Thyroid Pituitary Adrenal

• Anorexia nervosa • Athletic amenorrhea • Stress induced • Brain tumors • Psychotropic meds

Implications of Widespread Acceptance and Prescribing of Modified 21/7 Regimens?

• Ovarian tumors • Cervical stenosis • Uterine adhesions • Abnormal pregnancies

Modifications of 21/7 Regimens: Potential Reduction in: • Hormone withdrawal symptoms – Menstrual associated headaches – Pelvic pain / dymenorrhea – Cyclic mood swings / PMS

• Bleeding • Functional ovarian cysts • Ovulation / unintended pregnancy

Modifications of 21/7 Regimens: Potential Reduction in: • Healthcare costs – Sanitary protection – Pain medications – Office visits – Procedures: EMBx, TVS – Surgery: laparoscopy, ablation, hysterectomy

• Missed days from work, school, other responsibilities, social activities

Reducing Menstrual Amount / Frequency • Reducing incidence of anemia • Reducing pad / tampon use • Eco Friendly: STOP RED - - - GO GREEN

Incessant Ovulation / Bleeding: Associated Health Risks • • • • •

Anemia Endometriosis: pain, infertility Ovarian cysts Ovarian cancer PMS / PMDD

Adolescent Hormone Related Disorders • • • • • •

Irregular menstrual bleeding Menorrhagia Dysmenorrhea Premenstrual symptoms Facial acne Menstrual associated headaches

Conclusion 1. Menstrual disorders are common: dysmenorrhea, menorrhagia, irregular menses, menstrual migraines, PMS. 2. Menstrual disorders are less common in patients on OCs, but they still occur in a significant percentage and can affect compliance. 3. Modifications of the standard 21/7 day contraceptive regimens will improve the quality of life for many of our patients.

Scott & White Worth the Wait®

Contraception & Teens: Providing the FACTS!

Modifications in 21/7 Contraceptive Regimens Improved Quality of Life

Developed by the Scott & White Sex Education Program Scott and White Memorial Hospital and Clinic ©2004, Scott and White Memorial Hospital and Scott, Sherwood and Brindley Foundation