Heavy Menstrual Bleeding and Medication Challenges

Menorrhagia and Medication Issues

Hello, doctor.
I would like to ask about issues related to my menstrual cycle and medication.
My main symptoms include abnormal bleeding outside of my menstrual period and prolonged menstrual bleeding (lasting more than 10 days).
The dates of bleeding in May were from May 15 to May 31 (but I started having red discharge from May 6).
The bleeding dates in June are from June 6 to the present.
Due to the prolonged bleeding in May, I consulted a doctor on May 28, who prescribed 3 days of Estrogen (Estring) and 14 days of Provera.
I took Estrogen, but the bleeding did not stop.
Later, after taking Provera for a few days (during the days I stopped bleeding, I still noticed small blood clots when using the restroom), I started bleeding again on June 6.
On the third day of bleeding, June 8, I had blood tests (FSH: 9.29, LH: 6.91, E2: 48.58).
The doctor determined that the bleeding starting on June 6 was my menstrual period.
During my follow-up on June 11, the doctor prescribed Estrogen and Provera again to regulate my cycle.
(Medication record: May 28-30 Estrogen 2mg twice daily; May 31-June 13 Provera 5mg once daily; June 14-18 Estrogen 2mg twice daily).

Background of medication: Because I am overweight (BMI 30), one doctor suspected polycystic ovary syndrome (PCOS), so I started taking Metformin in March to stabilize my insulin levels, and my weight has decreased from 86 kg to 82.5 kg.
However, a second doctor reviewed my blood test results and said I do not have PCOS but can continue taking Metformin to control my weight.
I also have a habit of taking B vitamins (Kentamin Cap) irregularly.

I would like to ask the doctor: 1.
Why does the bleeding continue despite taking Estrogen? I am currently on my second round of Estrogen, but after two days, the menstrual flow has not decreased at all.
It is now the 10th day of my period, and the flow is still heavy enough to soak a full overnight pad.
The doctor originally prescribed a 5-day course, instructing me to continue taking Estrogen until the bleeding stops and then switch back to Provera.
However, if the bleeding does not stop after five days, what should I do? Should I continue taking Provera, or do I need to return for a follow-up? 2.
Since I am a virgin, the doctors have only been willing to perform abdominal ultrasounds over the past six months, and there have been no abnormalities found in the uterus, ovaries, or endometrial thickness.
However, the inability to find the cause of the abnormal bleeding is causing me psychological stress.
Is it necessary for me to request a pelvic exam from the doctor, or should I just continue taking medication and monitor my cycle? Thank you, doctor.

Eva, 30~39 year old female. Ask Date: 2022/06/16

Dr. Chen Zhiyu reply Obstetrics and Gynecology

Regarding your concerns, here is a response based on your description of excessive menstrual bleeding that cannot be controlled with medication.
For women who have had intimate relationships, a pelvic examination and transvaginal ultrasound are essential.
However, since you have never engaged in sexual intercourse, there will be certain limitations during the examination.
It is recommended that you visit a medical center or a facility of that level, where appropriate instruments that do not harm the private areas will be available to assist in completing an endometrial biopsy to determine the actual cause of the bleeding.
Thank you for your question, and I wish you health and happiness.

Reply Date: 2022/06/16

More Info

Heavy menstrual bleeding (HMB) can be a distressing condition, and it often requires a thorough evaluation to determine the underlying causes and appropriate treatment options. Based on your description, it seems you are experiencing prolonged and heavy menstrual bleeding, which has not responded adequately to the medications prescribed by your doctor. Let's break down your concerns and address them systematically.

Understanding Heavy Menstrual Bleeding
Heavy menstrual bleeding is defined as menstrual blood loss that is greater than what is considered normal, often leading to disruptions in daily activities and potential health issues such as anemia. The causes of HMB can vary widely and may include hormonal imbalances, uterine abnormalities (such as fibroids or polyps), clotting disorders, or other medical conditions.

Medication Challenges
1. Istradefylline (益斯得) and Provera (普維拉): These medications are often used to manage menstrual irregularities. Istradefylline is a medication that can help regulate menstrual cycles, while Provera is a form of progesterone that can help stabilize the endometrial lining and reduce bleeding. However, it is not uncommon for these medications to take some time to show effects, and individual responses can vary significantly.

- Why is the bleeding persisting despite medication? There are several reasons why your bleeding may not be stopping:
- Hormonal Imbalance: If your hormonal levels are not adequately balanced, the medications may not be effective. Your recent blood tests (FSH, LH, E2) indicate that your hormonal levels are within a range that suggests normal ovarian function, but individual responses can vary.

- Underlying Conditions: Conditions such as uterine fibroids or polyps may not have been detected through abdominal ultrasound. These can cause heavy bleeding and may require further investigation.

- Medication Adherence: Ensure that you are taking the medications as prescribed. Missing doses or not taking the full course can affect their efficacy.

- What to do if bleeding continues? If after five days of taking Istradefylline the bleeding has not decreased, it is essential to follow up with your healthcare provider. They may consider adjusting your medication, performing additional tests, or exploring other treatment options.

2. Need for Further Evaluation: Given that you are a virgin and have not had an internal examination, it is understandable that your doctors have opted for non-invasive methods initially. However, if the bleeding persists and remains unexplained, it may be worth discussing the possibility of a transvaginal ultrasound or an internal examination with your doctor. This can provide more detailed information about the uterus and ovaries, potentially identifying any abnormalities that could be contributing to your symptoms.

Psychological Impact
The ongoing issue of heavy bleeding can undoubtedly cause psychological stress. It is essential to address this aspect as well. Consider discussing your feelings with your healthcare provider, who may recommend counseling or support groups for individuals dealing with similar issues.

Conclusion
In summary, heavy menstrual bleeding can be complex and multifactorial. It is crucial to maintain open communication with your healthcare provider regarding your symptoms and treatment response. If the current medications are not effective, further evaluation may be necessary to identify any underlying conditions. Additionally, addressing the psychological impact of this condition is equally important for your overall well-being. Don't hesitate to seek a second opinion if you feel your concerns are not being adequately addressed. Your health and comfort are paramount, and there are various avenues to explore for effective management of your symptoms.

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