Managing menstrual health is crucial for many individuals, especially when it comes to dealing with irregular periods, heavy menstrual bleeding, or conditions like polycystic ovary syndrome (PCOS) and endometriosis. Menstrual regulation medications offer effective solutions for those seeking to regulate or delay their menstrual cycles, alleviate severe menstrual cramps, or address menstrual irregularities. In this comprehensive guide, we explore the different types of hormonal and non-hormonal menstrual regulation medications, their mechanisms of action, and the conditions they treat. Whether you’re dealing with missed periods due to hormonal contraceptives, looking for ways to manage heavy menstrual bleeding, or exploring menstrual suppression options, this article provides essential insights and guidance to help you make informed decisions about your reproductive health.
1. Introduction to Menstrual Regulation
Menstrual regulation refers to the ability to regulate irregular or lack of menstrual bleeding, usually in the case of hormonal contraceptive methods or in the presence of conditions where menses is interrupted due to hormonal conditions. Normally, pills would be used to accomplish the former and hormones would be used to accomplish the latter, until situations can be addressed that prevent a natural window between bleeding times. Menstrual regulation is especially important in the case of missed withdrawal bleeding after a woman has taken a course of birth control pills. Many women will experience what might appear to be a late period, often leading to stress and pregnancy worries. It’s always important to think and ask about medications or drugs before you try them, especially in the case of abuse and addiction. Additionally, no one should have to take medications to bleed every month if they do not have any problems or symptoms such as cramping and heavy bleeding, or amenorrhea, which are entirely controlled by the uterus and not due to change or failure in birth control methods.
First, menstrual regulation medication used in the medical profession shall be stated. To define menstruation or bleeding from the uterus induced by medications, the terms “menstrual regulation” or “induced bleeding” are mostly used in scientific literature. The medication used to induce bleeding from the uterus is various forms of the hormones called “estrogen,” all of which need to be given as a “boost” or “loading dose” for the first dose only. Menstrual regulation requires two doses 12 hours or 14 days apart. These forms of estrogen are combined with a class of hormones called progestins and given two in one day, one at least 12 hours later in either order.
1.1. Definition and Importance
Menstrual regulation, or menses regulation for people who menstruate, is the process of using medications to bring on a period or continue a period by ensuring that hormone levels can fall without new hormonal support. Mid-cycle, estrogen levels have topped off and the brain stops luteinizing hormone (LH) and follicle stimulating hormone (FSH) production in response to inhibin from the ovaries. Then, the lack of LH pulses causes the corpus luteum to stop making progesterone, causing the lining of the uterus to break down and start to bleed, as the shedding known as a menstrual period. These medications can be effective even in the presence of an intrauterine device (IUD).
We use the terminology “menstrual regulation” like most other specialists that provide this care, instead of the term “abortion,” a focus on the term “abortion” in scientific. However, we don’t believe that it medicalizes a normal clinical phenomena to discuss accomplishing a minor physiological task, such as beginning or continuing a menstrual period, in the same conversation as ending a pregnancy that is intended to continue 100% of the time. We also think it’s important to empower people who may decide between beginning and continuing a pregnancy in a visit for menstrual regulation, not to force themselves into a destiny by using more euphemistic language.
2. Different Types of Menstrual Regulation Medications
Menstrual regulation medications are prescribed to help regulate an individual’s menstrual cycle and are commonly used in the treatment of heavy menstrual bleeding, irregular or absent periods, and severe menstrual pain. These medications are often recommended for individuals with conditions such as endometriosis, polycystic ovary syndrome (PCOS), and fibroids. They may also be used by those who wish to delay their periods for reasons such as religious holidays, emergencies, or significant events. Additionally, transgender or non-binary individuals who menstruate might use these medications as part of their treatment plan. Menstrual regulation medications are broadly categorized into two types: hormonal and non-hormonal. However, it’s important to note that these medications are sometimes used off-label, meaning for purposes other than those originally approved. It’s essential to consult with a healthcare provider to determine if a menstrual regulation medication is appropriate for you.
Hormonal medications are the most commonly prescribed for menstruation regulation, delay, or management. These medications are classified based on the hormones they contain and their effects on the body. Traditional birth control pills, which contain estrogen and progesterone, are frequently used to treat menstrual irregularities, including heavy bleeding and dysmenorrhea (painful periods). Progestin-only medications, such as progestin-only pills and progesterone, are often prescribed for individuals who cannot use estrogen-based medications, such as those who are breastfeeding or younger individuals seeking period regulation. Transgender or non-binary individuals may also be prescribed progestin-only medications to suppress menstruation. Other hormonal treatment options include the levonorgestrel-releasing intrauterine system (LNG-IUS, brand name Mirena) and medroxyprogesterone acetate (brand name Depo-Provera), which are used both for treating specific conditions and in hormonal gender-affirming care for transgender women.
2.1. Hormonal Medications
There are two main categories of medications that can be used for menstrual regulation: those that work on hormone levels in the body and those that do not. This guide describes both types, but focuses more attention on hormonal medications because they are both more widely used and more widely available. The hormones that are used in these medications are mainly estrogen and/or progestin, which are chemically similar to the hormones that naturally occur in our bodies. A third type of medication – emergency contraceptive pills – can also be used for menstrual regulation. These pills contain hormones that work by either preventing or delaying the release of an egg from the ovaries, which alters the timing of ovulation and thus the menstrual period.
Combined oral contraceptives (“the combination pill” or “the minipill”) contain estrogen and progestin, and they are the most widely used hormonal medication for menstruation. Estrogen and progestin are hormones found naturally in women’s bodies. The combination pill is called such because it contains both of these hormones. This type of birth control pill suppresses menstruation. The birth control pill works by supplying an even level of hormones across the whole cycle. The pituitary in the brain senses these elevated levels of progestin and estrogen and stops making the hormones that are needed to ovulate. The brand of combination pill used will impact the effect on menstruation. The minipill, progestin-only birth control pills, contain only one type of hormone – progestin – that is found naturally in a woman’s body. The progestin-only birth control pill is designed to thicken cervical mucus, suppress ovulation, or do both things to prevent pregnancy. Because women can experience menstrual changes while using the progestin-only pill, it is another option for changing the timing of menstruation.
2.2. Non-Hormonal Medications
There are several subtypes of medication that aren’t hormonal but are sometimes used to regulate menstruation. Anti-inflammatory agents, such as nonsteroidal anti-inflammatory agents (NSAIDs), can reduce prostaglandin production and storage in animals. However, it is unclear whether NSAIDs have a similar effect on prostaglandins in people. Antifibrinolytics can improve symptoms of heavy menstrual bleeding by preventing clots from breaking down. Clotting is mediated by platelets in the blood; hence, it is understandable that antiplatelet medications (which might reduce clotting) might delay or reduce menstrual flow in some women.
For this review, we did not include information on hemostatic agents that a physician performs in the emergency department during vaginal bleeding with an unknown cause, as the cause of this bleeding is not known and some women may be pregnant. A woman seeking menstrual regulation can have a more thorough workup before starting medications than a woman being seen in an emergency department, where the immediate need is to determine if she is pregnant or treat anemia from bleeding. Tears, medications given to induce contraction and uterine emptying, and herbal or “natural” therapies, which may or may not be effective but are beyond the scope of this review, are also not discussed here. In addition, medicines that can temporarily slow the menstrual cycle, such as some antipsychotics and some medications used to regulate blood sugar (e.g., Metformin), are beyond the scope of this review.
3. Commonly Used Hormonal Medications
The first category of menstrual regulation medications we’ll discuss are hormonal medications. These include treatments for regulating the menstrual cycle as well as managing medically-diagnosed conditions like amenorrhea or polycystic ovary syndrome (PCOS). Hormonal medications can be used therapeutically to regulate menstruation and control bleeding, regardless of the underlying cause.
Medroxyprogesterone (Provera, Depo-Provera) is a progestin that can be used to regulate the menstrual cycle, treat heavy bleeding or pain associated with uterine fibroids or endometriosis, or manage persistent abnormal bleeding or regular heavy menstrual bleeding of cyclical origin. Medroxyprogesterone is a synthetic hormone that has a more pronounced effect on the uterus than on the endometrium or hypothalamus, although prolonged use can significantly impact these areas as well. It can be used for up to 4 months at a time without requiring additional estrogen.
Norethindrone (Acticon, Aygestin) can also be used for the same purposes as medroxyprogesterone. It is administered twice daily to treat both cyclical and non-cyclical cervical and uterine bleeding. The levonorgestrel intrauterine system (LNG-IUS, brand name Mirena) serves as both a highly effective contraceptive and a treatment for heavy menstrual bleeding. Its use for both indications is approved by the U.S. Food and Drug Administration (FDA). The effectiveness of Mirena increases with prolonged use, and it can alleviate pain regardless of its contraceptive function.
Norethindrone Acetate ER (Lo Loestrin Fe, Loestrin Fe, Junel Fe, etc.) is a daily contraceptive pill that contains the synthetic hormone ethinyl estradiol and a small dose of progestin. It can be used for several non-contraceptive purposes, either with regular twice-daily dosing or as a continuous daily low-dose regimen.
3.1. Combined Oral Contraceptives
Combined oral contraceptives have been used as a form of hormonal medication for over 60 years. They consist of two hormones, one of which is estrogen (ethinyl estradiol), the other a progestin (levonorgestrel, norethindrone, drospirenone, etc.). These hormones are used to maintain an ideal endometrium and safe hormonal profile over time. Combined hormonal options are generally well-tolerated with low and acceptable risks in healthy women. In addition to their contraceptive effects, combined hormones offer multiple non-contraceptive benefits. According to the American College of OBGYNs, combined hormonal contraceptives are used for medical indications in 14% of users, and the leading indication (33.3%) is to manage heavy menstrual bleeding/abnormal uterine bleeding.
Combined Oral Contraceptives: Mechanism: Provide a consistent hormonal environment to maintain the endometrium; Utility: Regulate menstrual bleeding, decrease menstrual blood loss and uterine cramping, treat dysmenorrhea (severe menstrual cramps), treat or prevent associated unpredictability of menstrual bleeding. Post-Abortion/Trauma Use: Given the other existing regimens (progestin-only methods and the LNG IUS) that are available for immediate post-abortion use, adding a COC as a post-abortion treatment/topper regimen is likely not necessary in high-resource or clinic settings. High progestin dosing after early medication abortion may be associated with nausea because some of the nauseating progesterone continues to be made in the mother. Patients should be counseled regarding this possibility.
3.2. Progestin-Only Pills
Progestin-only pills are a type of hormonal medication. They are sometimes used as contraceptives but are also used to regulate menses or ease overabundant menstruation, and so could be used for menstrual regulation. In the United States, progestin-only pills available as a contraceptive are sold under the brand names Camila, Errin, and Heather. They are sometimes called POPs (progestin-only pills) or the “mini-pill” in contrast to the “combined pills” with estrogen. Warning: If you vomit within 2 hours of taking progestin-only pills, you should take another pill to be sure that the dose isn’t lost.
Progestin-only pills must be taken every day at the same time of day in contrast to combined pills that allow for a week off. Each pack contains 28 pills and has to be taken every day. There are no placebo pills in each pack. The progestin in the pill keeps the lining from growing as thick as it generally would, and so menstrual flow is likely to be less than your normal period until you change from regular pill use. Many people do not menstruate during long-term use. This continues even more so if the regimen is continuous, which means skipping the inactive pills in each pack. The total pack must be finished to remain protected, not just the active pills. While they are not as effective when regularly forgetting to take a dose (popping a pill), the effect of progestin-only pills begins to wear off within 3 days of missing a dose (especially if missed during the days before and after the week without pills) within a few days.
4. Commonly Used Non-Hormonal Medications
When I discuss menstrual regulation medications with patients, the first drugs that often come to mind are those that affect the hormonal functions of the ovaries and uterus, such as mifepristone, levonorgestrel, and ulipristal acetate. However, these are just part of the first tier of menstrual regulation medications, which often include drugs that are tightly regulated or prohibited by law. The second tier consists of pharmaceutical options that temporarily manipulate hormone levels, while the third tier includes drugs that do not affect hormone levels at all. In this section, I will focus on the third category of medications. Non-hormonal options are commonly prescribed by healthcare professionals to manage menstrual cramps or the pain associated with certain surgical procedures, such as a head of hair surgical abortion. I will begin by outlining two standard dosing protocols, followed by a discussion on combining an NSAID with acetaminophen and the use of magnesium supplementation as a method to manage menstrual cramps.
Menstrual Pain: Medications to Prevent or Manage Cramps. Menstrual cramps are often caused by the contraction of uterine muscles in response to the release of prostaglandins. Menstrual pain can start as early as the day before bleeding begins and may last through the first three days of menstruation. Non-hormonal menstrual regulation medications can be safely administered to encourage menstrual bleeding, especially if symptoms of early pregnancy are present, if the person is between six and nine weeks of gestation (calculated from the first day of the last menstrual period), and if the healthcare provider is equipped to handle emergencies such as excessive bleeding, retained products of conception, or rare cases of ectopic pregnancy. These non-hormonal medications, including the prostaglandin analog misoprostol and the antiglucocorticoid/antiprogestin mifepristone, work independently of the hormones involved in the ovarian cycle.
4.1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
The duration of menstruation and the amount of blood flow depend largely on uterine contractions in its non-pregnant state and the sharp decline in hormone levels. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) can be used to interfere with the production of certain prostaglandins—hormones produced by the endometrium and the middle membrane of the myometrium. These prostaglandins, which are similar to parasympathomimetic prostaglandins, cause menstrual periods by inducing contractions. By reducing the production of menstrual-related prostaglandins, NSAIDs can help decrease uterine contractions. However, recent studies suggest that NSAIDs have a limited effect on prostaglandin production. Instead, they primarily work by suppressing the effects of prostaglandin mediators on the modulation and structure of pain-processing mechanisms in the body, or by reducing inflammation rather than affecting the external endometrial tissue. This means that, beyond their pain-relief effects, NSAIDs may also have anti-inflammatory properties that help resolve symptoms.
The Informed Health Network identified two tables of preferred NSAIDs. The first table lists 20 NSAIDs from the Key Questions in Healthcare department of the 2017 edition. These drugs are further categorized into nonselective and cyclooxygenase-2-selective subgroups. Nonselective NSAIDs are typically expressed in milligrams and are often used for the temporary treatment of fever and inflammation relief without the need for prescription drugs, usually providing pain relief for up to one week. Common brand-name drugs in this category include paracetamol and ibuprofen. Coxibs, a subgroup of NSAIDs, are under surveillance, especially for patients with or at increased risk of heart disease, and are typically monitored closely by healthcare providers if used for more than one week.
4.2. Tranexamic Acid
Tranexamic acid (sold under the brand names Lysteda and Cyklokapron) is a non-hormonal medication that is not often thought of as a menstrual regulation medication, but has been effectively used for just that for decades. It is an antifibrinolytic—the blood clot won’t break down and menstrual bleeding will be stopped. It’s most effective when taken with the very first sign of menses; the earlier used, the better the response. It can help prevent heavy bleeding in healthy patients and stop heavy bleeding once it has started. While tranexamic acid will not decrease the length of menses, it can decrease bleeding by 30-40% if taken the first few days of menses. Perimenopausal women using tranexamic acid for heavy bleeding found their quality of life lowly improved. It may be beneficial to start it at the first signs of menses, even before period pain happens.
Tranexamic acid has shown to most effectively decrease blood loss the first and second days of menses. Studies show that the average duration of use of tranexamic acid was 4 days. Dosing should be started at the first sign of menses, and it should be taken 2-3 times daily. The average AUB patient can expect about a 40% reduction in the first menses’s bleeding while on tranexamic acid. Side effects include nausea, vomiting and diarrhea. Some headache, nasal and/or sinus symptoms have been reported, but rare. Tranexamic acid is not approved for women with diseases or disorders at risk for thromboembolic events. If no substantial reduction has not been seen by the third menses, it is unlikely it will become more successful.
5. How Menstrual Regulation Medications Work
Hormonal medications used for menstrual regulation, such as progestogens and combined hormonal contraceptives, work by stabilizing the hormonal fluctuations that occur during the menstrual cycle. This stabilization can alleviate premenstrual symptoms, including those associated with premenstrual dysphoric disorder, premenstrual syndrome, and premenstrual irritability. On the other hand, non-hormonal medications, like NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) and tranexamic acid, reduce the production of prostaglandins—hormone-like molecules involved in various bodily processes, including muscle tightening and inflammation in the uterus. By reducing these prostaglandins, these medications help decrease uterine muscle contractions.
Through these ‘mechanisms of action,’ the uterus can be encouraged to behave more predictably, shedding its lining in a more orderly fashion. This can result in a more regular and manageable menstrual cycle. The medications used for menstrual regulation, while varying in their specific functions, all contribute to the process of helping the uterus shed its lining or preventing the lining from thickening, ultimately inducing a menstrual period. Some people also use these medications to skip their periods in situations where menstruation is undesirable, such as during religious or cultural ceremonies where bleeding is not permitted.
NSAIDs, in particular, work at the muscle level in the uterus to reduce contractions, making periods more manageable. They also lower the levels of prostaglandin F2, a natural substance responsible for strong muscle contractions and a significant contributor to menstrual cramps (dysmenorrhea). High doses of ibuprofen, taken up to three times per day, and naproxen are both effective NSAIDs for this purpose.
5.1. Mechanism of Action of Hormonal Medications
Hormonal medications used for therapeutic abortion or menstrual regulation include oral, intramuscular agents, and long-acting reversible contraceptives (LARCs). Some of these medications, while not specifically registered for abortion, can be used off-label for this purpose. The dosages are typically provided by the manufacturer and are used for either therapeutic abortion or menstrual regulation, depending on the indication.
During the menstrual cycle, the body undergoes various changes controlled by different hormonal signaling pathways. These hormones regulate the ovaries and the endometrium (the lining of the womb) to prepare the endometrium for the potential implantation of a fertilized egg.
The primary action of most hormonal medications is to supplement or replace natural hormones in the body, which disrupts the endometrium, making it unsuitable for the implantation and maintenance of a fertilized egg. Once the medication is discontinued, and hormone levels return to normal, the uterus contracts, expelling the fertilized egg and the accompanying tissue (including the fetus and placenta). This process clears the uterine lining.
A smaller subset of hormonal medications may also prevent ovulation by affecting the sperm’s ability to reach the egg, thereby preventing fertilization.
5.2. Mechanism of Action of Non-Hormonal Medications
As we have discussed, medications used for menstrual regulation can be broadly categorized into hormonal and non-hormonal types. While hormonal medications primarily work by suppressing endometrial growth and creating an anovulatory state, non-hormonal medications have a different mechanism of action.
Non-hormonal medications primarily target smooth muscle function. Smooth muscle is found in the walls of blood vessels, airways in the lungs, the stomach, intestines, and the uterus. Unlike skeletal muscle, which we can control voluntarily, smooth muscle operates involuntarily, responding to environmental signals through hormones and the nervous system. This type of muscle plays crucial roles in various bodily functions, such as maintaining blood pressure, aiding digestion by moving food along the intestines, and facilitating childbirth by helping push the baby out. However, this also means that its malfunction can be challenging to manage.
In the context of menstrual regulation, the smooth muscle in the uterus contracts at different points in the menstrual cycle. These contractions help the uterus shed its lining, leading to menstrual blood loss, or in cases of pregnancy, expel the pregnancy tissue. Non-hormonal medications work by influencing these contractions, helping manage the menstrual cycle or aiding in the termination of a pregnancy.
6. Indications for Menstrual Regulation
After proper counseling, women can be prescribed any of the following categories of drugs for menstrual regulation (MR):
– Misoprostol: Misoprostol is the first-line therapy for MR. It is administered orally, and the typical dosage is 600 mcg. It can be given at different times of the day, such as 8 am, 2 pm, or 10 pm. Misoprostol can be used by all women, regardless of whether they are breastfeeding. However, it should not be administered to women who have a known allergy to the drug.
– Mifepristone: Mifepristone is reserved for women who cannot take Misoprostol due to contraindications. It is used in combination with Misoprostol. Mifepristone can be administered at any time, regardless of when the last menstrual regulation procedure was performed. However, caution is advised for women who started breastfeeding immediately after delivery.
– Cyto-Technique: This is another combination therapy that includes Mifepristone and Misoprostol. Both drugs are administered together, with an additional dose of Waheso given 48 hours after Mifepristone.
– Menfeggyl: This combination of Mifepristone and Misoprostol can be used by women regardless of the time since the last menstrual regulation procedure or abnormal uterine bleeding (AUB). However, it is not recommended for women who have received a blood transfusion before using MR or those with a hemoglobin level less than 8 g/dL.
A continuing pregnancy may indicate the failure of MR. This is particularly the case if the uterus is 14 weeks in size or larger, or if there is retained fetal tissue inside the uterus, as observed during an irrigation and curettage procedure.
6.1. Menstrual Irregularities
Menstrual cycles and menstruation have long been subjects of interest and concern for women of all ages. Menstrual cycles may be regular or irregular due to various factors such as stress, lifestyle changes, weight fluctuations, dietary changes, hormonal imbalances, ovulatory disorders, polycystic ovary syndrome (PCOS), endometriosis, and more. Women may seek to regulate or change their menstruation to regain a sense of control and ease.
Menstrual irregularities can now be medically managed, even for women who are not using contraceptive pills or those who are breastfeeding, through the use of specific medications. So, how do menstrual regulation tablets work in these situations, and what other symptoms can they treat and manage?
Typically, oral contraceptive pills used to regulate the menstrual cycle establish a standardized or “controlled” cycle. Menstrual regulation tablets are not the same as contraceptive pills; they contain different active agents and are only authorized for menstrual cycle regulation, not contraception. These tablets are particularly effective in managing heavy menstrual bleeding (such as menorrhagia) and can also reduce menstrual flow and associated symptoms.
6.2. Heavy Menstrual Bleeding
Menstrual regulation medications are crucial in managing heavy menstrual bleeding. These medications can minimize or even eliminate periods by thinning the lining of the uterus. While these medications are often prescribed off-label to assist women with heavy periods, they are most effective when taken routinely and on a scheduled basis.
This section focuses on how menstrual regulation medications can help manage heavy menstrual bleeding. The goal in managing heavy periods is not to eliminate bleeding entirely but to reduce it to a level that is more manageable and akin to a natural menstrual cycle without medical intervention.
When menstrual regulation medications thin the uterine lining, the amount of bleeding decreases. However, the uterus will still undergo its contractive phases, which can cause discomfort during menstruation. Some patients may prefer, and be candidates for, eliminating bleeding entirely. For this to be achieved, the medication must thin the uterine lining to a minimal, healthy layer, so there is not enough tissue to be shed. This section will further review how to manage heavy menstrual bleeding and the different classes of medications that are typically used to decrease bleeding.
7. Contraindications and Precautions
There are specific situations where women and girls should exercise caution or avoid using menstrual regulation (MR) medications. These situations are known as contraindications.
– Age and Smoking: Women under 40 who smoke should avoid using ulipristal MR medication, as smoking combined with this medication increases the risk of thrombosis.
– Weight Considerations: Caution is also advised when using a combination of ulipristal and other medications in overweight women, as the effectiveness of this combination decreases with a body mass index (BMI) above 30 kg/m².
– Breastfeeding: The World Health Organization (WHO) does not recommend breastfeeding within one week of taking MR medications. Therefore, these medications are contraindicated for mothers during the first week of breastfeeding. Mothers should ensure they take the first dose of medication before breastfeeding.
– Allergies and Pregnancy: MR medications should not be used by women who are allergic to the active ingredients or if they suspect they are pregnant, especially if there is a confirmed diagnosis of an ectopic pregnancy. In such cases, further examination is required to determine the need for medical intervention in settings where it is allowed. Additionally, there is a slightly increased risk of ectopic pregnancy in women who have used MR medication within the first three months of pregnancy. This risk can be mitigated through a follow-up program, but the final decision should be made in consultation with a physician and with the patient’s consent.
7.1. Medical Conditions That May Prevent the Use of Menstrual Regulation Medications
Certain medical conditions may prevent the safe use of MR medications:
– Intrauterine Pregnancy or Bleeding: Women who have an intrauterine pregnancy or unexplained bleeding that may indicate pregnancy should avoid MR medications. Infrequent bleeding typically does not require a pregnancy test before taking the medications.
– Lack of Access to Care: Women who are unable to follow up with a qualified healthcare provider via phone or in person within the first 24 hours after taking the medication, or who lack access to emergency care in case of complications like bleeding, should not use MR medications.
– Concurrent Medications: Women who are taking antiarrhythmics for atrial fibrillation, theophylline (Theo-Dur) for asthma, certain steroids for conditions other than asthma, certain non-nucleoside reverse transcriptase inhibitors for HIV, efavirenz (Sustiva) for HIV, or anticoagulants or blood thinners for conditions other than heart disease or stroke prevention should avoid MR medications.
– Anemia: Women with a hemoglobin concentration below 8.0 g/dL at baseline or those with a history of anemia who exhibit symptoms such as pale skin, fatigue, exercise intolerance, dizziness, or fainting should be closely monitored. These symptoms may require referral for emergency care.
– Hormonal Sensitivity: Women taking hormonal contraceptives or therapeutic hormone replacement therapy are recommended to use the minimum effective dosages (e.g., combined oral contraceptive with 20 micrograms ethinylestradiol) due to increased sensitivity to progestogens in their uterus.
– Non-Hormonal Alternatives: For women who cannot use hormonal agents, the insertion of a non-hormonal copper-containing intrauterine device (IUD), along with the use of progesterone agonists, may concomitantly decrease pregnancy risk.
8. Side Effects and Risks
Most practitioners recommend that menstruation should resume within 4 to 8 weeks after taking menstrual regulation medications. If menstruation does not resume within this timeframe, do not attempt to self-medicate to induce menstruation again; it is crucial to consult a trained healthcare provider. After taking menstrual regulation medication, approximately 40-70% of users will experience their period within 9 days, with most starting within 2 weeks. Always consult a healthcare professional if you have any concerns.
The side effects of menstrual regulation medications can vary depending on the drug and the individual. Common side effects include nausea, vomiting, diarrhea, dizziness, fatigue, mild abdominal cramping, bloating, headache, fever, and shivering. Many healthcare professionals, including experienced family planning trainers and supervisors, have extensive knowledge of these medical methods and are well-equipped to handle any complications or rare occurrences.
Serious side effects, although rare, can occur and include blood clots in the limbs (deep vein thrombosis), blood clots in the lungs (pulmonary embolism), heart attack, stroke, high blood pressure, and severe, uncontrollable menstrual bleeding. These complications typically occur a week or two after the medication is administered. If any of these side effects occur, it is imperative to seek medical attention immediately. However, it is important to understand that the risks associated with using these medications are significantly lower than the risks of continuing with an untreated or unsafe menstrual regulation process or an unsafe abortion. Consultation with a midwife and/or doula is recommended in settings where they have the necessary training and medication to assist.
8.1. Common Side Effects
Common side effects of menstrual regulation medications typically include:
– Nausea, vomiting, diarrhea, abdominal pain, fatigue, headache, dizziness, and heavy bleeding.
These side effects are generally not serious and are experienced by many women who use menstrual regulation medications. They usually do not require specific treatment, as they tend to be self-limiting and resolve within 24 to 48 hours after taking the medication.
Many women report feeling nauseous (less often vomiting or experiencing diarrhea) within an hour or two after taking the first dose of the menstrual regulation medication. This reaction is believed to be due to the effect of the misoprostol, which can cause a sudden flushing of the uterus. Although some women may continue to feel unwell when taking subsequent doses of misoprostol or mifepristone, many report feeling better afterward. The most common expected reactions to these medications, along with other side effects, often indicate that the medication is working. Later on, after taking each dose, some women use ibuprofen to alleviate symptoms such as stomach upset, vomiting, diarrhea, or pain.
8.2. Serious Risks and Complications
Serious risks and complications associated with medications like Misoprostol or Mifepristone include:
– Severe and life-threatening blood loss (hemorrhage)
– Serious respiratory issues or heart rhythm disturbances (dysrhythmias)
– Heart damage, central nervous system (CNS) problems, shock, and systemic infections
If initial or follow-up dilation and curettage (DC) does not occur, there is a risk of congenital malformations in an unborn child. Retaining these medications in the system for an extended period can lead to serious complications in a developing fetus, including skeletal, skin, neurological, cardiovascular, immune, and connective tissue disorders.
**Infection Risk:** Using laminaria, a seaweed-based cervical dilator, can introduce bacteria from the vaginal canal, potentially leading to infections. A woman may not be aware of such an infection and could suffer from a typical yeast infection. If left untreated, this could result in systemic yeast infections or additional candidiasis infections. Progesterone, when used with certain devices, can increase the risk of vaginal yeast infections. Uncommon bacterial infections may occur due to contamination during the insertion of laminaria or other medical devices.
9. Interactions with Other Medications
Understanding potential drug interactions is a crucial aspect of using any medication, including those used for menstrual regulation. Interactions are more likely to occur when an individual is taking multiple medications or when medications interact with substances from diet or the environment. Most interactions are considered mild to moderate, but in cases where research is limited, making clear recommendations about drug combinations can be challenging. Whenever introducing a new substance into the body, it’s important to be cautious and vigilant for any new side effects.
There are limited studies examining the interactions of mifepristone, misoprostol, and levonorgestrel used for menstrual regulation. This guide includes tables that highlight some known contraindications and cautions for mifepristone and misoprostol regimens to assist healthcare providers. However, these tables may not be exhaustive or completely up to date. Many factors can increase the risk of drug interactions, and it’s advised that clinicians use their expertise to assess potential risks when data is lacking.
9.1. Drug Interactions to Be Aware Of
Drug Interactions Overview:
Drug interactions occur when medications affect one another’s efficacy or safety. There are few well-conducted studies on how medications for menstrual regulation interact with other drugs. Therefore, it is crucial to be aware of possible interactions when these medications are taken alongside others. Currently, we know that women using the following drugs simultaneously with mifepristone may require higher doses to avoid reduced effectiveness:
– Enzyme inducers: Certain anticonvulsants
– Antifungal drugs: Griseofulvin
– Antibiotics: Rifampin (used for TB and leprosy), rifabutin (for TB and mycobacteria), rifapentine (for TB, except TB meningitis), fusidic acid (a macrolide antibiotic), ofloxacin (antibiotic), fluconazole (antifungal)
– Herbal supplements: St. John’s wort, Hypericum, Klamath weed, goatweed, amber touch-and-heal, rosin rose
– Other substances: Zyrtec, Claritin, Loestrin, Ortho-Novum, Vitex, Primrose Oil, preparations containing Herba Sennae, Herba chestnut, Herba taxilli, Fructus cnidii, Semen myristicae, Senna oil, Blumea oil, Mentholum, Parahydroxybenzoate, Emulsified wax, and Lanolin
Mifepristone is metabolized by the liver’s Cytochrome P450 3A4 enzyme system. Therefore, any agent that increases this enzyme’s activity is likely to reduce mifepristone levels and its effectiveness. Some drugs have been shown to alter the levels of mifepristone and other similar medications (e.g., UL). Oral contraceptives do not significantly alter mifepristone or UL levels compared to non-users, but there is some evidence that they may reduce the risk of ovulation returning if the medication is not taken properly. UT3 has been detected in women taking hormonal contraceptives, but it is unclear whether these levels are sufficient to provide additional contraceptive effects.
10. Choosing the Right Menstrual Regulation Medication
For some women, the menstrual cycle passes without much notice, marked only by a slight change in flow. However, for many others, the menstrual cycle is something to endure rather than celebrate. The reasons for this vary: physical pain, a history of trauma, or personal discomfort with bleeding are just a few examples. The number of reasons is as varied as the solutions, not all of which are medical. When it comes to choosing the right menstrual regulation medication (MRM), the options can be overwhelming, and finding the most suitable one requires careful consideration.
When selecting an MRM, the first step is to understand what each option offers, the likely outcomes given certain factors (such as infections, multiple pregnancies, etc.), contraindications, and potential side effects. It’s important to discuss the patient’s priorities and ensure they align with the expected results. Additionally, when finances are a concern, the patient should be informed that while cheaper options are available, they may need to consider a backup plan with a more expensive option if necessary. This section will guide you through the process of designing an effective plan.
10.1. Factors to Consider
As you explore the best medication option for you, consider the following factors:
– Administration Preference: Do you prefer to administer the medication yourself, or would you rather have a healthcare provider do it? How comfortable are you with a healthcare provider, and what type of relationship do you want to have with them during this process? We will discuss the different methods of obtaining a menstrual regulation prescription in the next section, “Where and How Can I Access Menstrual Regulation Medications?”
– Timing: What is your time frame for starting the medication? How soon after a positive pregnancy test are you seeking care? While the effectiveness window for menstrual regulation can vary, in general, the longer it has been since conception, the harder it may be to obtain medication for menstrual regulation. Currently, mifepristone is rarely available as a standalone menstrual regulation method in low- and middle-income countries like Tanzania and Ethiopia, and obtaining misoprostol for less invasive gynecological procedures like menstrual regulation can become more difficult as the pregnancy progresses.
– Medical Conditions and Healthcare Access: Do you have any medical conditions or live in an area with healthcare restrictions that might make one method more suitable than another? Certain health conditions may make it safer for you to use a specific type of medication, or may require additional check-ups with a healthcare provider. Some methods may be easier to obtain than others. If you have medical conditions that necessitate a particular method, it’s advisable to seek care where that method is available.
11. Administration and Dosage
If the woman is not Rh-negative, the medications can be administered on an outpatient basis. For women who are Rh-negative, as per the standard of care for any treatment involving an incomplete abortion, prophylactic anti-D gamma globulin should be administered. While antibiotics have been given prophylactically to women taking misoprostol following a medical abortion, there is no conclusive evidence that antibiotics reduce the risk of pelvic infection after using menstrual regulation medications. Anesthesia is generally unnecessary, though women may take nonsteroidal anti-inflammatory drugs (NSAIDs) before the procedure to manage discomfort. Misoprostol can cause increased cramping and heavier bleeding.
For menstrual regulation using misoprostol, the standard regimen is 800 μg taken buccally (in the cheek) 24-72 hours after taking mifepristone. Both regimens have proven to be effective. Misoprostol is typically dosed at 200 mcg, administered orally or vaginally every 3-12 hours as needed, up to a maximum of 800 mcg per day. Women can expect bleeding and other signs of the abortion to begin within 1-4 hours after taking misoprostol. The presence of residual non-viable trophoblastic tissue is extremely rare in developing countries. The prolonged use of misoprostol or NSAIDs is generally not recommended unless required to manage heavy bleeding. Treatment is essential if excessive bleeding persists or is heavier than the woman’s typical menstrual flow. Hematologic complications are rare, and magnesium sulfate can be used as a uterine muscle relaxant to help expel retained products more effectively.
11.1. Proper Usage Instructions
Each administration note includes a section for individualized recommendations on proper usage procedures and best practices. These detailed instructions ensure that all parties fully understand how to use the medications effectively.
Menstrual Regulation Medication Usage Instructions
If a woman is pregnant and chooses to use menstrual regulation medications to terminate the pregnancy, she should first take a pregnancy test to confirm the pregnancy before using any medication. After confirming the pregnancy, she can take one of the menstrual regulation medications as instructed in the administration note. The initial medication will begin to break down the pregnancy, leading to cramping and bleeding, and eventually result in the body expelling the pregnancy on its own. This process may begin within a few hours after taking Mifepristone and/or Misoprostol, but in some cases, it may take longer. Almost everyone who uses these medications will start to bleed and cramp within a few hours of taking Misoprostol. However, each person’s body is unique. If bleeding or cramping does not occur within 24 hours of taking Mifepristone, it is recommended to try again with Misoprostol. The timing can vary, so it is crucial for those considering menstrual regulation medications to closely follow the provided guidelines. These instructions should be thoroughly reviewed and followed each time the treatment cycle is initiated.
12. Monitoring and Follow-Up
This section covers the monitoring and follow-up processes required after the use of menstrual regulation medications. Monitoring and follow-up are crucial to ensure that the medications are working effectively and to detect any potential complications early. This section addresses how patients should be monitored during treatment, what symptoms should be observed, and why follow-up visits are important.
12.1 Monitoring during Menstrual Regulation
1. In every case, a registered medical technician is responsible for oversight, supervision, and approval of monitoring and follow-up.
2. During this time, the woman will be monitored to ensure that she is improving physically and receiving necessary emotional, social, and spiritual support. There is no evidence supporting the need for multiple follow-up visits; however, she should be informed that initial bleeding is the expected outcome and be advised on the type and amount of pain to anticipate. If she is not feeling better, she should return for further evaluation.
3. Monitoring for complications should occur if one or more signs and symptoms are present once the woman returns. Surveillance is not necessary for clients without signs or symptoms.
12.2 Reasons and Plan for the Monitoring Visit
1. The first visit with a medical technician after taking medications is critical. This visit provides an opportunity to establish a connection with the woman, assess whether she may be experiencing a serious complication that requires immediate referral, and provide her with protective information. It also serves as a point of contact for any uncommon or severe side effects or general feelings of illness. If her pain exceeds what she typically experiences during menstruation after using the medications, she should be referred to a health facility.
2. Adverse events that should not be considered a normal outcome of Menstrual Regulation are listed in the question and answer section of the glossary. All health facilities should have adequate treatment protocols for handling these complications, and all medical technicians should be knowledgeable about the appropriate actions for these symptoms. There is no evidence suggesting that women should or should not be allowed to use misoprostol for menstrual regulation on their own in private settings without disclosing their use of the medication. However, women should be informed, supported, and offered follow-up to monitor their progress if they choose to do so. Further support should also be provided if they opt for any other legally available and safe procedure to end a pregnancy. Some women may prefer to have the procedure done or supervised by a medical technician. There is no fixed rule; each situation must be considered based on the woman’s circumstances and realities. The technician may reassure her that she is doing well and has no infection. She can leave and return if she develops any symptoms of complications. In the meantime, a follow-up visit is not mandatory nor time-bound. However, women should be educated to assess any abnormal or severe pain and understand what types of bleeding and vaginal expulsion to expect. This way, they can recognize normal processes and differentiate them from unusual experiences that require action. It is challenging for the medical technician to assist if the woman does not return until late in a severe illness. Everyone involved should work towards improving care during these challenging times in women’s lives.
12.3 Importance of Follow-Up Visits
You will be asked to attend at least two, and possibly three, follow-up visits. The counseling and readiness assessment visit is crucial—please make sure to attend. It is important to discuss any experiences, telephone conversations, uterine bleeding, or pain issues you may have had with the clinic staff. This can often be difficult, so please make an effort to discuss anything that troubled you. All visits are important because we are using ‘medication’ rather than just treating pain or bleeding. Additionally, we want to ensure that all pregnancy products are expelled from your uterus. Although we initially monitor the amount of beta HCG, regular follow-up by you, the doctor, and the staff provides the best assurance.
This follow-up helps prevent any ongoing pregnancy and/or the rare need for a suction procedure. Occasionally, you may refuse certain questions or interventions, which is reasonable and will not stop the treatment. However, because you are managing the medication yourself, do not hesitate to call the clinic if you need help with pelvic pain or vaginal bleeding that seems unusual. If possible, we prefer that you come in for an evaluation. Essential dos and don’ts:
– Do not engage in sexual intercourse from the beginning of the treatment until the bleeding stops and you feel back to normal. You have a high risk of getting an infection, and you may become pregnant again.
13. Emerging Trends and Research
According to W. S. Pearson, S. Gorstein, and A. Seth (2019), there are two notable emerging trends in the use of menstrual regulation medications (MRM):
1. The increased use of more effective medications, such as mid-level gestational medications. However, as second-trimester procedures shift from conventional methods to medication-based abortion techniques, access to MRM is diminishing. Consequently, the number of clinical trials involving subjects in the second trimester is decreasing.
2. In low-resource environments, medical professionals are experimenting with new techniques to improve record access, procedure efficiency, and patient acceptability. As a result, the research on MRM is becoming increasingly diverse in terms of content, activities, and measurement tools. In this evolving research landscape, new goals for MRM highlight the need for expansion in both clinical research and program implementation.
Ongoing research by L. P. Darney, MSc; L. E. Polis, PhD; and W. S. Pearson, MD, has shown that surgical and medical termination of pregnancy technologies have advanced significantly since the last survey, focusing on practicality, effectiveness, and patient engagement.
Furthermore, technological advancements in early abortion methods have allowed procedures to occur at lower levels of the healthcare system, closer to a woman’s home. These advancements have opened new opportunities for pharmacokinetic studies on medications like mifepristone and misoprostol, which are challenging to understand due to their variable effects on the body. High-quality studies examining the pharmacokinetic properties of these medications, particularly concerning age, BMI, and administration routes, are needed. The results of such studies could lead to the development of new, indication-based medication regimens. Potential benefits include adjustments in estradiol dosing, long-acting gonadotropin applications, and possibly even a transition from a two-dose to a one-dose regimen approved by the Food and Drug Administration (FDA). Some MR medications may enable menstruation within weeks of administration.
13.1. New Developments in Menstrual Regulation Medications
Recent developments in menstrual regulation medications have shown that mifepristone, followed by misoprostol, is more effective than using mifepristone alone for medical abortion. This finding, supported by a meta-analysis of randomized controlled trials, is particularly significant for hospitals, health centers, and pharmacies that provide medical abortions, offering new insights into the field of menstrual regulation and management.
Contextually, menstrual regulation (MR) can be achieved through the use of various medications. The practical application of these medications continues to evolve as new research emerges, complicating the field due to the frequent lack of standardized brand names and variations in chemical structures of medications used for similar purposes. Recommendations based on the WWH-OPT algorithm suggest that mifepristone is a safe and effective option to initiate the MR process. However, it is important to note that using mifepristone alone may result in a longer time for the uterus to expel its contents compared to combined medication regimens. Patients should be informed of this and be prepared to either remain in the healthcare facility or return after an appropriate waiting period to complete the MR process if using only mifepristone.
14. Conclusion
In conclusion, menstrual regulation medications are employed to either initiate or expedite the onset of a menstrual cycle. Among these, medroxyprogesterone acetate is the most commonly prescribed medication, with strong evidence supporting its efficacy in the literature. Other medications, such as promethazine, hormone-containing oral contraceptives, norethindrone, and dopamine agonists or antagonists, have shown varying degrees of effectiveness. Despite the interest, there is limited clinical evidence to support the routine use of mifepristone/misoprostol for menstrual regulation.
The administration of these medications can lead to a range of side effects, many of which are associated with the withdrawal of hormones at the end of the cycle, prompting menstruation. While most patients prefer to undergo this process at home, a small number may opt for physician supervision to receive counseling or medical intervention if necessary. It is crucial to personalize the treatment plan based on the latest research, the patient’s previous experiences with medication, and their preferences, considering the associated risks and effectiveness rates.
14.1. Key Takeaways
Here are the key insights from this guide on menstrual regulation medications:
– Menstrual regulation (MR) is a process aimed at clearing the uterus and expelling any residual tissue.
– Healthcare providers should be knowledgeable about this process, including the medications used and the specific situations in which they are effective.
– Evidence supports the use of a single dose of Mifeprex for early pregnancy loss.
– While various medications have been reviewed, only a few have strong evidence backing their use in menstrual regulation.
– The effectiveness of medications in clearing the uterus after pregnancy, whether or not there is fetal cardiac activity, remains uncertain.
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