Period problems: Can contraception help?
By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, FAAP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
Staff Physician
University of Pittsburgh Student Health Service
Up to 90% of female adolescents report experiencing painful periods or other menstrual complaints. Problems associated with menses are the primary reported cause for absenteeism from school and work for female adolescents.1 While diagnosis and treatment differ depending on specific menstrual disorders or complaints, contraceptive methods often offer a solution for teens and adults.
Dysmenorrhea is the most common menstrual complaint. It includes cramps and pain in the lower abdomen before and during menses. It often is accompanied by nausea, back pain, headache, vomiting, and diarrhea. These symptoms are more common during mid- or late adolescence because they are more likely to occur once ovulation begins. The production of prostaglandins following progesterone withdrawal is the part of a normal menstrual cycle that leads to an inflammatory response that can cause pain and other symptoms. Most dysmenorrhea occurs in women with normal cycles and no pelvic pathologies, which is termed primary dysmenorrhea.
Treatment for primary dysmenorrhea includes the use of around the clock non-steroidal anti-inflammatory drugs (NSAIDs) for two to three days prior as well as throughout menses to reduce prostaglandin production. If this treatment is not effective within three cycles, a cycled combination hormonal contraceptive, such as an oral contraceptive pill (OCP) usually is the next suggested treatment. OCPs reduce prostaglandin production, thin the endometrial lining, and inhibit ovulation, which might provide relief. Women who still experience pain and other symptoms during withdrawal bleeds might want to consider continuous cycling.2 Using dedicated continuous cycling pills, or using the vaginal ring without a withdrawal bleed, would produce similar relief.
While NSAIDs and OCPs historically have been considered first-line options for relieving dysmenorrhea, studies indicate depot medroxyprogesterone acetate injections can reduce symptoms by up to two-thirds.3 Also, there is growing support for use of the five-year levonorgestrel intrauterine system (LNG-IUS) (Mirena, Bayer HealthCare Pharmaceuticals, Whippany, PA) for management of dysmenorrhea. A 10 mcg combination pill, such as Lo Loestrin (Actavis, Parsippany, NJ) often causes amenorrhea and can act as another way to manage dysmenorrhea. If dysmenorrhea continues, providers might suspect secondary dysmenorrhea caused by pelvic pathology such as pelvic inflammatory disease or endometriosis. Further interventions might be necessary to identify the cause.
There can be several causes of abnormal uterine bleeding. The first step in addressing this problem is assessing the amount of bleeding and ensuring the patient is hemodynamically stable. Providers should evaluate for the cause of the abnormal bleeding and offer appropriate treatments to reduce bleeding irregularities. Anovulation accounts for nearly 90% of abnormal bleeding during adolescence.2 Without ovulation, a lack of progesterone creates an unstable endometrial lining. This lining breaks down, which leads to excessively long and heavy periods and irregular bleeding. Anovulatory cycles are extremely common in the first years after menarche; combination hormonal contraceptives can produce regular bleeding patterns. However, combined pills do not affect the body’s ability to regularly ovulate.3 Adolescents with mild to moderate bleeding with no anemia require minimal intervention, with the exception of tracking their menses on a calendar and maintaining their dietary iron intake. Teens experiencing heavy menstrual bleeding or menorrhagia might require additional work-up for diagnosis and should be offered a range of treatment options.
Menorrhagia can be a symptom of more serious bleeding disorders. Up to 20% of adolescents admitted to hospitals with sever menorrhagia have an underlying clotting disorder or bleeding diathesis, the most common of which is Von Willenbrand disease.4 Other disorders might include platelet dysfunction, clotting factor deficiencies, or thrombocytopenia, which might be primarily hematologic in origin or a result of liver function abnormalities. Treatment of menorrhagia is based on the amount of flow, degree of anemia, and shared decision-making between the patient, provider, and parents.
For patients with mild to moderate bleeding and no signs of anemia, NSAIDs and combination hormonal contraceptives, or a LNG-IUS, can reduce bleeding.2, 4-6 Adolescents with active bleeding and signs of moderate to severe or acute anemia, especially if they are hemodynamically unstable, will require more aggressive hormonal intervention, or even hospitalization, for treatment.
It should be noted that pregnancy, including ectopic or spontaneous abortion, also might be a cause of bleeding, as well as amenorrhea. A urine pregnancy test is recommended for female adolescents experiencing bleeding or amenorrhea.
While there is no research available specifically on the use of intrauterine devices (IUDs) by female adolescents to relieve menstrual complaints and disorders, the research on levonorgestrel-releasing intrauterine systems in adult women provides useful guidance for the care of younger patients. Numerous studies have shown this method to significantly improve dysmenorrhea in older women ages 25-47.6 One such study found a 30% reduction in menstrual pain in LNG-IUS users after 36 months.7 Studies of young adult women ages 18-25 also have reported the LNG-IUS providing more relief from dysmenorrhea compared to OCPs.8
There is a lack of adolescent-specific research on the treatment of heavy menstrual bleeding using the IUS, but data on adult women is encouraging.9 One study of women with heavy menstrual bleeding found an 86% reduction in bleeding after three months, and it found a 97% reduction after 12 months of LNG-IUS use.10 A Cochrane review later reported that LNG-IUS led to greater reductions in bleeding than OCPs for adult women with heavy menstrual bleeding.11 Even among women with normal bleeding patterns, the LNG-IUS reduces significantly more bleeding than OCPs, studies indicate.8
While offering adolescents effective contraceptive options for preventing pregnancy is always a best practices, these studies reveal how many methods, especially combination hormonal contraceptives, progestin-only injections, and the LNG-IUS, also contribute important noncontraceptive benefits by resolving menstrual problems and disorders for adolescents, regardless of their need for pregnancy prevention.
References
- Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics 1981; 68:661-664.
- Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol 2006; 19:363-371.
- Harel Z, Biro FM, Kollar LM. Depo-Provera in adolescents: effects of early second injection on prior oral contraception. J Adolesc Health 1995; 16:379-384.
- Slap G. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol 2003; 17:75-92.
- Wilkinson JP, Kadir RA. Management of abnormal uterine bleeding in adolescents. J Pediatr Adolesc Gynecol 2010; 23:S22-30.
- Bayer LL, Hillard PJ. Use of levonorgestrel intrauterine system for medical indications in adolescents. J Adolesc Health 2013; 52(4 Suppl):S54-58.
- Baldaszti E, Wimmer-Puchinger B, Loschke K. Acceptability of the long term contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3 year follow-up study. Contraception 2003; 67:87-91.
- Suhonen S, Haukkamaa M, Jakobsson T, et al. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception 2004; 69:407-412.
- Matteson KA, Rahn DD, Wheeler TL, et al. Society of Gynecologic Surgeons Systematic Review Group. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol 2013; 121(3):632-643.
- Anderson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia. Br J Obstet Gynaecol 1990; 97:690-694.
- Lethaby AE, Cooke I, Rees M. Progesterone/progestogen releasing intrauterine systems versus either placebo or any other medication for heavy menstrual bleeding. Cochrane Database Syst Rev 2000: CD002126.
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