Menstrual manipulation: Options for suppressing the cycle

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An intrauterine device

Intrauterine devices were originally developed as contraceptives. The addition of a progestin to these devices has been shown to reduce heavy menstrual bleeding by up to 90%.24,25

Mirena IUS, a levonorgestrel-releasing device, is the only medicated intrauterine device that is currently available in the United States. (“IUS” stands for “intrauterine system.”) It was recently approved by the FDA to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of pregnancy prevention.26 About 50% of women who use this device develop amenorrhea within 6 months of insertion, while 25% report oligomenorrhea.27

The Mirena device can be left in the uterus for up to 5 years. It may be a good choice for inducing amenorrhea in women with hemostatic disorders or in whom estrogen either is contraindicated or causes health concerns.18 The copper intrauterine device (Paragard; Duramed Pharmaceuticals Inc., Pomona, NY) remains a viable option for those who cannot or do not tolerate hormonal therapy. However, Mirena may provide less unscheduled bleeding than the copper intrauterine device.

Depot medroxyprogesterone acetate injections

Depo-Provera (depot medroxyprogesterone acetate) injections are given at 90-day intervals. 28 This contraceptive method inhibits ovulation and decidualizes the endometrium, thereby reducing or eliminating uterine bleeding. 29

While new users may initially experience excessive prolonged bleeding (10 or more days) while shedding their existing lining, the rate of amenorrhea has been shown to increase over time as the lining atrophies.30 Thus, prolonged use of this agent reduces the frequency of menstruation as well as menstruation-related symptoms.

Depot medroxyprogesterone acetate is ideal for patients whose menstrual periods pose a significant hygiene problem (eg, developmentally challenged girls). In our experience, the injections can be given at shorter intervals to induce atrophy of the endometrium quickly. In this scenario, the clinician might give an injection every 4 to 6 weeks for two or three doses to induce amenorrhea and then return to every-12-week dosing.

The main risk when using medroxyprogesterone injections to induce amenorrhea is the potential for bone loss. Users of this method have been shown to have lower mean bone mineral density31–33 and significantly higher levels of biomarkers of bone formation and resorption32,34 than nonusers. However, these changes are similar to those seen in breastfeeding women,35 are reversible with cessation, 36 and are not associated with increased fracture risk.37 In adolescent girls, pregnancy poses similar risks to the bones, with longerterm consequences.

Medroxyprogesterone can also stimulate appetite, causing 10 to 20 kg of weight gain in adolescents and women who are already obese and have trouble with appetite regulation.38 Slender users tend not to gain weight, however.

Given this information, depot medroxyprogesterone acetate appears to be a cost-effective contraceptive option that should be considered in the context of the clinical situation and preference of each patient.

Transdermal contraceptive patch

Ortho Evra, a transdermal patch, is designed to deliver ethinyl estradiol 0.02 mg and norelgestromin 0.150 mg daily.39 It is usually applied weekly for 3 weeks, followed by a patch-free week to induce regular monthly withdrawal bleeding.

Extended use of the patch to manipulate menstruation is an off-label use. In the only trial evaluating extended use of the patch, amenorrhea occurred in 12% of users, but unscheduled bleeding and spotting were common. 16

Although there is some evidence that the long-term use of the patch may increase the risk of venous thromboembolism,40,41 the risk in women who use the patch has been found to be similar to that in women using an oral contraceptive.42 However, serum ethinyl estradiol levels have been found to be higher with the use of the weekly patch than with oral contraceptives or the contraceptive vaginal ring39; as a result, many physicians are hesitant to recommend its continuous use.

Pending further data about the safety profile of this contraceptive, the World Health Organization Medical Eligibility Criteria for Contraceptive Use suggest that the same guidelines for the prescription of combination oral contraceptives should also apply to the patch.43

Contraceptive vaginal ring

NuvaRing, a contraceptive vaginal ring, releases a daily dose of ethinyl estradiol 0.015 mg and etonogestrel 0.12 mg.10 It is inserted, left in for 21 days, and then removed and left out for 7 days, during which withdrawal bleeding occurs.10

Vaginal administration has been shown to allow low, continuous dosing, which results in more stable serum concentrations than with the patch or oral contraceptives.39 In the only trial comparing an extended vaginal ring regimen and the traditional 28-day regimen, extended use resulted in fewer overall days of bleeding than monthly use, but with more unscheduled spotting.15

The most common side effects include headache, vaginitis, and leukorrhea,44 but there is no evidence of bacteriologic or cytologic changes in the cervicovaginal epithelium, even with extended use.45,46

Etonogestrel implantable contraceptive

Implanon, a single-rod progestin implant, is available in the United States and elsewhere. It is placed subdermally in the inner upper arm and provides contraception for as long as 3 years.

Implanon contains 68 mg of the progestin etonogestrel, which it slowly releases over time, initially at 0.06 to 0.07 mg/day, decreasing to 0.035 to 0.045 mg/day at the end of the first year, to 0.03 to 0.04 mg/day at the end of the second year, and then to 0.025 to 0.03 mg/day at the end of the third year.47

The amount of vaginal bleeding associated with the use of the implant is generally modest, but the pattern tends to be unpredictable. 48 In addition, because amenorrhea is reported as a side effect in only 22% of women during the first 2 years of its use,48 the progestin implant is a less satisfactory means of menstrual suppression than the other methods discussed above.

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