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ACOG Pub Review > CC#3: General Approaches to Medical Management of Menstrual Suppression > Flashcards

CC#3: General Approaches to Medical Management of Menstrual Suppression Flashcards

1
Q

Definition of menstrual suppression

A

Use of hormonal meds to decrease frequency/volume of physiologic menses (in some cases achieving amenorrhea)

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2
Q

General goal of menstrual suppression

A

Reduction in amount and total days of menstrual flow

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3
Q

Do hormonal methods used to suppress menses affect future fertility; do hormonal methods used to suppress menses increase risk of cancer?

A

No; no (continuous combined OCPs may actually decrease risk of certain cancers)

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4
Q

Point of withdrawal bleeding during placebo week of traditional OCP dosing

A

Purely to mimic more “natural” cycle, not necessary for health

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5
Q

Available formulations of COCs that can be given continuously (2)

A

Monophasic formulation (w/ discarding/omitting placebo week and starting immediately w/ next pack on Day 22), extended-cycle formulation

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6
Q

Over how many consecutive cycles is it safe to omit the placebo week of a COC pack?

A

Indefinitely

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7
Q

Comparing standard-cycle COCs to extended-cycle COCs, which method has better contraceptive efficacy and safety?

A

Methods are comparable

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8
Q

Limitations to continuous-dosing COCs (2)

A

BTB, hormonal adverse effects

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9
Q

Percentage of pts on continuous COCs reporting amenorrhea at 2 months; at 6 months; at 12 months

A

49%; 68%; 88%

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10
Q

Advantages of continuous-dosing COCs compared to other menstrual suppression options (2)

A

Long hx of provider/pt experience; higher doses (ie >20mcg EE) result in less BTB

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11
Q

Disadvantages of continuous-dosing COCs compared to other menstrual suppression options (2)

A

Daily compliance, variable duration of menstrual suppression before BTB (though sxs improve w/ successive cycles)

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12
Q

Strategies to manage BTB on continuous-dosing OCPs (4)

A

Counseling that BTB decreases w/ each successive cycle, can consider cyclic cycles x3-6 months then transition to extended cycles, can attempt hormone-free interval for 3-4 consecutive days, can supplement w/ intermittent estrogen

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13
Q

Benefits of extended-regimen CHC patch over standard-regimen CHC patch (3)

A

Fewer median bleeding days, fewer bleeding episodes, fewer spotting episodes

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14
Q

How to take CHC patch continuously

A

Apply every week (no patch-free week)

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15
Q

Limitations to continuous CHC patch (3)

A

BTB, hormonal adverse effects, skin reaction

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16
Q

General amenorrhea rates on extended-cycle of CHC patch

A

Moderate (on 6mg norelgestromin + 0.75mcg EE patch)

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17
Q

Advantage of continuous CHC patch compared to other menstrual suppression options

A

Weekly compliance (easier than daily OCPs)

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18
Q

Disadvantages of continuous CHC patch compared to other menstrual suppression options (2)

A

Limited data, patch adherence

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19
Q

How to use Nuvaring continuously

A

Place monthly (w/ immediate replacement following removal and w/o ring-free week)

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20
Q

Limitations to continuous Nuvaring (2)

A

BTB, hormonal adverse effects

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21
Q

General amenorrhea rates on extended-use regimen of Nuvaring

A

Excellent (using 0.12mg etonogestrel + 0.015mg EE w/ avoidance of any ring-free interval)

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22
Q

Advantage of continuous-dosing Nuvaring compared to other menstrual suppression options

A

Compliance (easier than daily/weekly methods)

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23
Q

Disadvantage of continuous-dosing Nuvaring compared to other menstrual suppression options

A

Higher discontinuation rates 2/2 BTB (although bleeding days are reduced w/ extended cycling, spotting days increased)

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24
Q

Commonly available formulations of POPs that can be used for menstrual suppression (2)

A

Norethindrone acetate 5mg BID-TID, Provera

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25
MoA of POPs in developing menstrual suppression
Endometrial atrophy
26
Limitations to continuous-regimen POPs (3)
Irregular bleeding, progestin-related adverse effects, adverse effects on lipids
27
General amenorrhea rates w/ norethindrone 0.35mg daily; amenorrhea rates w/ norethindrone acetate 5mg daily
Low (discontinuation rate up to 48.5% at 1 year); 76% (menstrual irregularity improves w/ more prolonged use)
28
Advantages of continuous-dose POPs compared to other menstrual suppression options (2)
Availability for pts in whom estrogen is contraindicated, adjustable oral dosing
29
Disadvantages of continuous-dose POPs compared to other menstrual suppression options (3)
Inconsistent achievement of amenorrhea, more expensive than COCs, need for consistent/strict adherence 2/2 narrow therapeutic window (return to baseline hormonal levels within 24h of administration)
30
Strategies to manage BTB when using continuous-dose POPs (3)
Inconsistent achievement of amenorrhea, more expensive than COCs, need for consistent/strict adherence 2/2 narrow therapeutic window (return to baseline hormonal levels within 24h of administration)
31
Depo formulations (2)
150mg IM shot, 104mg subQ shot; both methods given q11-13 weeks
32
Limitations of Depo shot when used for menstrual suppression (4)
BTB, progestin-related adverse effects, weight gain, reversible effect on BMD w/ use >2 years
33
Amenorrhea rates at 2 years of Depo use
68-71% (increases w/ more prolonged use)
34
Administration technique that may (anecdotally) increase rates of amenorrhea w/ Depo use
Administration at more frequent intervals
35
Disadvantages of Depo compared to other menstrual suppression options (2)
Weight gain, potential reversible effects on BMD
36
Strategies to manage BTB on Depo (3)
5-7 day NSAID trial, hormonal tx w/ 10-20 days of COCs/estrogen (if medically eligible), administration at more frequent intervals
37
Recommended duration of use of Nexplanon if used for menstrual suppression
3 years
38
Limitation to Nexplanon use for menstrual suppression
High rates of menstrual irregularity
39
Amenorrhea rates w/ Nexplanon use
~22% (increases w/ more prolonged use
40
Advantage of Nexplanon compared to other menstrual suppression options
Top-tier contraceptive efficacy
41
Disadvantages of Nexplanon compared to other menstrual suppression options (2)
Initial expense, insertion-related pain/discomfort
42
Strategies to manage BTB on Nexplanon (3)
5-7 day NSAID trial, hormonal tx w/ 10-20 days of COCs/estrogen (if medically eligible), trial of POPs for pts w/ contraindications to estrogen
43
Recommended formulation of LNG-IUD when used for menstrual suppression
52mg device (releases 20mcg daily), exchanged q7 years
44
MoA of LNG-IUD in developing menstrual suppression
Endometrial glandular atrophy w/o consistent suppression of ovulation
45
Limitations of LNG-IUD (3)
Initial BTB, possible hormonal effects (improve w/ time), unpredictable suppression of ovulation
46
Amenorrhea rates associated w/ LNG-IUD at 1 year; at 5 years
50%; 60% (highest w/ 52mg devices)
47
Advantages of LNG-IUD compared to other menstrual suppression options (2)
Top-tier contraceptive efficacy, benefits for medical conditions (ie HMB, endo, adeno, fibroids)
48
Disadvantages of LNG-IUD compared to other menstrual suppression options (2)
Initial expense, insertion-related pain/discomfort
49
Strategies to manage BTB on LNG-IUD (3)
Counseling that pts using lower-dose IUD experience more bleeding/spotting days on average than those using 52mg LNG-IUD, trial of NSAIDs/doxy/POPs/continuous OCPs, counseling pts on alternative methods
50
Available routes of delivery of GnRH agonists (4)
PO, IM, subdermal implant, intranasal
51
Interval of dosing of GnRH agonists
Daily, q12 weeks (depending on formulation)
52
Limitations of GnRH agonists (3)
Initial stimulatory effect (w/ associated increase in bleeding) before suppression, menopausal sxs, adverse effects on BMD w/ prolonged use
53
General amenorrhea rates w/ GnRH agonists
High
54
Advantage of GnRH agonists compared to other menstrual suppression options
High rate of amenorrhea
55
Disadvantages of GnRH agonists compared to other menstrual suppression options (3)
Menopausal effects limit tx (but may be mitigated w/ hormonal add-back tx), very expensive, potential effect on BMD
56
General principle of counseling when choosing candidates for menstrual suppression options
Always apply US MEC to determine safety
57
Do adolescent pts need to wait a certain period of time after FMP to begin menstrual suppression?
No (though pt must have FMP first in order to indicate typical pubertal development)
58
Is a routine pelvic exam required for rx of menstrual suppression methods?
No, unless needed for device insertion (ie IUD)
59
Major considerations for menses in gender-diverse pts (2)
Dysphoria w/ menses, attitudes/safety concerns regarding public restroom use for menstrual hygiene
60
Management of continued bleeding in setting of gender-affirming testosterone use
Progestin-only therapy
61
Is there risk for endometrial hyperplasia/malignancy 2/2 aromatization of exogenous testosterone to estrogen w/ anovulation (chronic unopposed estrogen) w/ gender-affirming testosterone use?
No--this is theoretical and not supported by data, and most studies demonstrate endometrial atrophy associated w/ exogenous testosterone use
62
Management option for gender-diverse pts desiring pubertal blockade and suppression of menses (along w/ provision of gender-affirming hormone tx)
GnRH analogs
63
Amenorrhea rates w/ use of GnRH therapy in transgender pts
Near 100%
64
Limitation of GNRH therapy in transgender pts
Concerns about effects on BMD, so not a long-term method of menstrual suppression (same as in cisgender pts)
65
Counseling point for transgender pts w/ reproductive potential when using testosterone and/or GnRH analogs
Testosterone and GnRH analogs are not effective contraceptive methods
66
General counseling strategy for adolescent pts w/ physical/cognitive disabilities when it comes to managing their own menses
Most pts who are able to use the toilet w/o assistance can learn to use pads/tampons appropriately
67
Education points for pts w/ cognitive disabilities/knowledge deficits (4)
Hygiene, contraception, STIs, abuse-prevention
68
H&P elements to be aware of when considering options for menstrual suppression in pts w/ cognitive/physical disabilities (5)
Comorbidities that would act as contraindications to certain methods, extent of pt mobility, presence of upper and/or lower extremity contractions, ability to swallow pills, potential for drug interactions (ie w/ anti-seizure meds)
69
How to choose a menstrual suppression approach for pts that do not have capacity to make independent decisions
Approach must be made in pt's best interests by designated decision maker(s) (ie via options that are lowest risk and reversible)
70
Ethical principle to uphold when providing care to pts w/ disabilities (4)
Confidentiality, dignity/respect, autonomy, avoidance of harm
71
Knowledge topics to assess/address in pts w/ disabilities (5)
Puberty, menstruation, sexuality, safety, consent
72
Additional considerations for pts w/ disabilities who are taking OCPs (2)
Ability to adhere to daily regimen, ability to swallow pills (which can be crushed, or rx for chewable OCPs provided)
73
Additional considerations for pts w/ disabilities who are taking patch (2)
Consideration of skin irritation, may place patch in area not easy to access (ie between shoulder blades) for pts prone to picking
74
Additional consideration for pts w/ disabilities who are taking vaginal ring
Invasive for pts w/ contractures who will require assistance
75
Additional considerations for pts w/ disabilities who are taking Depo (2)
Decreased BMD considerations especially pertinent to pts who use wheelchairs/are immobile, potential weight gain may limit independence for pts who are immobile and/or negatively affect caregivers' ability to care for pt
76
Additional considerations for pts w/ disabilities who are using a LARC method (3)
Consider general anesthesia/conscious sedation for pts in whom pelvic exam would be challenging for cognitive/mobility reasons, consider anesthesiology consultation before procedure, coordinate exam under anesthesia/sedation w/ other procedure (ie dental work) if possible
77
Environments in which limited access to medical services/sanitary equipment exists, w/ associated increased inconvenience/logistic difficulty/privacy of hygienic management of menstruation (5)
Military deployment to severe environments (ie war zones), incarcerated pts, pts w/ housing insecurity, pts who work in remote locations, athletes
78
Common difficulties faced by homeless pts re menstrual management (3)
Limited access to menstrual products, limited access to resources to avoid stigmatizing menstrual accidents, limited access to public restrooms to maintain hygiene
79
Potential concerns re menstrual management among incarcerated pts (2)
Difficulty accessing menstrual products and clean undergarments, systems may be set up to provide/deny products to incarcerated people as a reward/punishment
80
Benefit of continuous-dose COCs/progestin-only meds when given w/ other meds used concurrently
May provide more predictable effects on other meds concurrently used 2/2 avoidance of change in drug levels during hormone-free break
81
Most common reason for discontinuation/changing menstrual suppression methods; percentage of pts who cite this as reason for discontinuation/changing methods
BTB; up to 46%
82
Counseling points for pts w/ BTB on menstrual suppression, regardless of method used (2)
Reassurance of benign nature of bleeding, sxs often improve w/ prolonged use (3-6 months)

ACOG Pub Review (18 decks)

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