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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
Q

MoA of POPs in developing menstrual suppression

A

Endometrial atrophy

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26
Q

Limitations to continuous-regimen POPs (3)

A

Irregular bleeding, progestin-related adverse effects, adverse effects on lipids

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27
Q

General amenorrhea rates w/ norethindrone 0.35mg daily; amenorrhea rates w/ norethindrone acetate 5mg daily

A

Low (discontinuation rate up to 48.5% at 1 year); 76% (menstrual irregularity improves w/ more prolonged use)

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28
Q

Advantages of continuous-dose POPs compared to other menstrual suppression options (2)

A

Availability for pts in whom estrogen is contraindicated, adjustable oral dosing

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29
Q

Disadvantages of continuous-dose POPs compared to other menstrual suppression options (3)

A

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)

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30
Q

Strategies to manage BTB when using continuous-dose POPs (3)

A

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)

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31
Q

Depo formulations (2)

A

150mg IM shot, 104mg subQ shot; both methods given q11-13 weeks

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32
Q

Limitations of Depo shot when used for menstrual suppression (4)

A

BTB, progestin-related adverse effects, weight gain, reversible effect on BMD w/ use >2 years

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33
Q

Amenorrhea rates at 2 years of Depo use

A

68-71% (increases w/ more prolonged use)

34
Q

Administration technique that may (anecdotally) increase rates of amenorrhea w/ Depo use

A

Administration at more frequent intervals

35
Q

Disadvantages of Depo compared to other menstrual suppression options (2)

A

Weight gain, potential reversible effects on BMD

36
Q

Strategies to manage BTB on Depo (3)

A

5-7 day NSAID trial, hormonal tx w/ 10-20 days of COCs/estrogen (if medically eligible), administration at more frequent intervals

37
Q

Recommended duration of use of Nexplanon if used for menstrual suppression

A

3 years

38
Q

Limitation to Nexplanon use for menstrual suppression

A

High rates of menstrual irregularity

39
Q

Amenorrhea rates w/ Nexplanon use

A

~22% (increases w/ more prolonged use

40
Q

Advantage of Nexplanon compared to other menstrual suppression options

A

Top-tier contraceptive efficacy

41
Q

Disadvantages of Nexplanon compared to other menstrual suppression options (2)

A

Initial expense, insertion-related pain/discomfort

42
Q

Strategies to manage BTB on Nexplanon (3)

A

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
Q

Recommended formulation of LNG-IUD when used for menstrual suppression

A

52mg device (releases 20mcg daily), exchanged q7 years

44
Q

MoA of LNG-IUD in developing menstrual suppression

A

Endometrial glandular atrophy w/o consistent suppression of ovulation

45
Q

Limitations of LNG-IUD (3)

A

Initial BTB, possible hormonal effects (improve w/ time), unpredictable suppression of ovulation

46
Q

Amenorrhea rates associated w/ LNG-IUD at 1 year; at 5 years

A

50%; 60% (highest w/ 52mg devices)

47
Q

Advantages of LNG-IUD compared to other menstrual suppression options (2)

A

Top-tier contraceptive efficacy, benefits for medical conditions (ie HMB, endo, adeno, fibroids)

48
Q

Disadvantages of LNG-IUD compared to other menstrual suppression options (2)

A

Initial expense, insertion-related pain/discomfort

49
Q

Strategies to manage BTB on LNG-IUD (3)

A

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
Q

Available routes of delivery of GnRH agonists (4)

A

PO, IM, subdermal implant, intranasal

51
Q

Interval of dosing of GnRH agonists

A

Daily, q12 weeks (depending on formulation)

52
Q

Limitations of GnRH agonists (3)

A

Initial stimulatory effect (w/ associated increase in bleeding) before suppression, menopausal sxs, adverse effects on BMD w/ prolonged use

53
Q

General amenorrhea rates w/ GnRH agonists

A

High

54
Q

Advantage of GnRH agonists compared to other menstrual suppression options

A

High rate of amenorrhea

55
Q

Disadvantages of GnRH agonists compared to other menstrual suppression options (3)

A

Menopausal effects limit tx (but may be mitigated w/ hormonal add-back tx), very expensive, potential effect on BMD

56
Q

General principle of counseling when choosing candidates for menstrual suppression options

A

Always apply US MEC to determine safety

57
Q

Do adolescent pts need to wait a certain period of time after FMP to begin menstrual suppression?

A

No (though pt must have FMP first in order to indicate typical pubertal development)

58
Q

Is a routine pelvic exam required for rx of menstrual suppression methods?

A

No, unless needed for device insertion (ie IUD)

59
Q

Major considerations for menses in gender-diverse pts (2)

A

Dysphoria w/ menses, attitudes/safety concerns regarding public restroom use for menstrual hygiene

60
Q

Management of continued bleeding in setting of gender-affirming testosterone use

A

Progestin-only therapy

61
Q

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?

A

No–this is theoretical and not supported by data, and most studies demonstrate endometrial atrophy associated w/ exogenous testosterone use

62
Q

Management option for gender-diverse pts desiring pubertal blockade and suppression of menses (along w/ provision of gender-affirming hormone tx)

A

GnRH analogs

63
Q

Amenorrhea rates w/ use of GnRH therapy in transgender pts

A

Near 100%

64
Q

Limitation of GNRH therapy in transgender pts

A

Concerns about effects on BMD, so not a long-term method of menstrual suppression (same as in cisgender pts)

65
Q

Counseling point for transgender pts w/ reproductive potential when using testosterone and/or GnRH analogs

A

Testosterone and GnRH analogs are not effective contraceptive methods

66
Q

General counseling strategy for adolescent pts w/ physical/cognitive disabilities when it comes to managing their own menses

A

Most pts who are able to use the toilet w/o assistance can learn to use pads/tampons appropriately

67
Q

Education points for pts w/ cognitive disabilities/knowledge deficits (4)

A

Hygiene, contraception, STIs, abuse-prevention

68
Q

H&P elements to be aware of when considering options for menstrual suppression in pts w/ cognitive/physical disabilities (5)

A

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
Q

How to choose a menstrual suppression approach for pts that do not have capacity to make independent decisions

A

Approach must be made in pt’s best interests by designated decision maker(s) (ie via options that are lowest risk and reversible)

70
Q

Ethical principle to uphold when providing care to pts w/ disabilities (4)

A

Confidentiality, dignity/respect, autonomy, avoidance of harm

71
Q

Knowledge topics to assess/address in pts w/ disabilities (5)

A

Puberty, menstruation, sexuality, safety, consent

72
Q

Additional considerations for pts w/ disabilities who are taking OCPs (2)

A

Ability to adhere to daily regimen, ability to swallow pills (which can be crushed, or rx for chewable OCPs provided)

73
Q

Additional considerations for pts w/ disabilities who are taking patch (2)

A

Consideration of skin irritation, may place patch in area not easy to access (ie between shoulder blades) for pts prone to picking

74
Q

Additional consideration for pts w/ disabilities who are taking vaginal ring

A

Invasive for pts w/ contractures who will require assistance

75
Q

Additional considerations for pts w/ disabilities who are taking Depo (2)

A

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
Q

Additional considerations for pts w/ disabilities who are using a LARC method (3)

A

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
Q

Environments in which limited access to medical services/sanitary equipment exists, w/ associated increased inconvenience/logistic difficulty/privacy of hygienic management of menstruation (5)

A

Military deployment to severe environments (ie war zones), incarcerated pts, pts w/ housing insecurity, pts who work in remote locations, athletes

78
Q

Common difficulties faced by homeless pts re menstrual management (3)

A

Limited access to menstrual products, limited access to resources to avoid stigmatizing menstrual accidents, limited access to public restrooms to maintain hygiene

79
Q

Potential concerns re menstrual management among incarcerated pts (2)

A

Difficulty accessing menstrual products and clean undergarments, systems may be set up to provide/deny products to incarcerated people as a reward/punishment

80
Q

Benefit of continuous-dose COCs/progestin-only meds when given w/ other meds used concurrently

A

May provide more predictable effects on other meds concurrently used 2/2 avoidance of change in drug levels during hormone-free break

81
Q

Most common reason for discontinuation/changing menstrual suppression methods; percentage of pts who cite this as reason for discontinuation/changing methods

A

BTB; up to 46%

82
Q

Counseling points for pts w/ BTB on menstrual suppression, regardless of method used (2)

A

Reassurance of benign nature of bleeding, sxs often improve w/ prolonged use (3-6 months)

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