February 2019

Medical conditions commonly worsen during the luteal phase and menses.¹ This may reflect the complex and often poorly understood interplay of hormones with other physiologic processes throughout the body. Seizures, asthma, mental health disorders, and migraines are among the conditions more commonly exacerbated during a woman’s menstrual cycle. Anita Nelson and Lee Shulman offer guidance on interrupting the cycling interplay of hormones and exacerbation of medical conditions in their chapter on the Menstrual Cycle in the new edition of Contraceptive Technology.²

A classic example is menstrual migraines.³ About 7% to 9% of women with migraine headaches have them only with menses. Another 35% to 40% of migraine sufferers experience worsening of headaches with menses.⁴ Attacks of menstrual migraines are usually more debilitating, last longer, are more likely to recur, and are less responsive to medical therapies than non-menstrual migraine attacks.^5,6  One therapeutic approach to menstrual migraine headaches has been to treat prophylactically with standard migraine treatments during at-risk times. Some have recommended home fertility monitors to predict menses more accurately so therapy can be better timed.⁷ However, because headaches have been definitely linked to a decline in estrogen levels,⁸ another approach has been to suppress menses with extended cycle hormones or to provide estrogen supplementation during bleeding days. The use of estrogen is appropriate only for patients under 35 years of age who do not suffer neurologic auras preceding the onset of their migraines and do not suffer worsening of their headaches with estrogen exposure. The progestin-only pill with desogestrel (not available in the United States), which reliably suppresses ovulation, has been found to be equally effective as combination oral contraceptives, but is not contraindicated in migraineurs with aura.⁹ DMPA, which suppresses ovulation and induces amenorrhea, would be preferred over LNG IUS, which does not control the hormonal cycling. Triptans have also been found to be effective for both acute treatment and for short-term prevention of menstrual migraine.³

Patients with seizure disorders frequently experience acute exacerbations of their convulsive activity with menstruation. More than one third of women with epilepsy are affected by catamenial (menses-related) epilepsy;^10,11 these seizures rarely respond to antiepileptic medications. Premenstrual increases in asthma attacks have been reported in up to 40% of women with asthma.¹² Virtually every woman knows that acne tends to blossom around the time of menses. Less common medical conditions that flare at menses include acute intermittent porphyria, diabetes, erythema multiforme, glaucoma, hereditary angioedema, rheumatoid arthritis, and multiple sclerosis.

Mental health problems tend to become more symptomatic with menses. Patients with anxiety disorders and pain disorders tend to experience more anxiety and panic attacks during menses. Symptoms of obsessive-compulsive disorders have been found to increase before menstruation, and patients with psychotic disorders also tend to suffer more intense symptoms during menses.¹³ Worsening of schizophrenia symptoms during the luteal phase has been reported.¹³ There is some evidence that women with bulimia may experience increased food cravings pre-menstrually.¹⁴

Suppressing ovulation alone (ENG implant) or eliminating menses by controlling the endometrium alone (LNG IUD) may not be sufficient therapy for patients whose medical conditions fluctuate in response to hormonal cycling. However, it is possible to prevent hormonal fluctuations with DMPA or extended cycle use of combined hormonal methods. Selection of the appropriate method depends upon underlying health, as well as personal preferences and specific symptom(s) presentation.

Individuals with chronic medical problems, depending on their condition, may benefit from menstrual suppression, write Rebecca Allen and Carrie Cwiak in Contraceptive Technology’s 21st edition.¹⁵ This non-contraceptive benefit may be an important part of contraception decision-making process for some women with conditions that are exacerbated during the menstrual cycle. For patients with heavy menstrual bleeding or sickle cell anemia, for example, the menstrual suppression provided by their contraceptive may actually improve their medical condition while providing effective protection from unintended pregnancy, just as it does for women with menstrual migraines. A hormonal method that reduces menstrual blood loss and dysmenorrhea may be of particular benefit for patients with severe anemia or women on anticoagulants. Long-term benefits such as protection against ovarian and endometrial cancer may be important to patients with a family history of ovarian cancer or with chronic anovulation, respectively.

¹ Pinkerton JV, Guico-Pabia CJ, Taylor HS. Menstrual cycle-related exacerbation of disease. Am J Obstet Gynecol 2010;202:221–31
² Nelson A, Shulman L. Menstrual cycle: normal patterns, menstrual disorders, and menstrually-related problems. . In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.
³  Brandes JL. The influence of estrogen on migraine: a systematic review. JAMA 2006;295:1824–30
⁴ Granella F, Sances G, Allais G, et al. Characteristics of menstrual and nonmenstrual attacks in women with menstrually related migraine referred to headache centres. Cephalalgia 2004;24:707–16
⁵ Nierenburg Hdel C, Ailani J, Malloy M, Siavoshi S, Hu NN, Yusuf N. Systematic review of preventive and acute treatment of menstrual migraine. Headache 2015;55:1052–71
⁶ Pavlović JM, Stewart WF, Bruce CA, et al. Burden of migraine related to menses: results from the AMPP study. J Headache Pain 2015;16:24.
⁷ MacGregor EA, Frith A, Ellis J, Aspinall L. Predicting menstrual migraine with a home-use fertility monitor. Neurology 2005;64:561–3.
⁸ Somerville BW. The role of estradiol withdrawal in the etiology of menstrual migraine. Neurology 1972;22:355–365.
⁹ Warhurst S, Rofe CJ, Brew BJ, et al. Effectiveness of the progestin-only pill for migraine treatment in women: A systematic review and meta-analysis. Cephalalgia 2017:333102417710636. Epub ahead of print.
¹⁰ Khishfe BF. Catamenial epilepsy: The menstrual cycle as a clue to predict future refractory seizures. J Emerg Med 2017;52:235–237.
¹¹ Foldvary-Schaefer N, Falcone T. Catamenial epilepsy: pathophysiology, diagnosis, and management. Neurology 2003;61:S2–15.
¹² Tan KS. Premenstrual asthma: epidemiology, pathogenesis and treatment. Drugs 2001;61:2079–86.
¹³ Hsiao MC, Hsiao CC, Liu CY. Premenstrual symptoms and premenstrual exacerbation in patients with psychiatric disorders. Psychiatry Clin Neurosci 2004;58:186–90.
¹⁴ Gladis MM, Walsh BT. Premenstrual exacerbation of binge eating in bulimia. Am J Psychiatry 1987;144:1592–5.
¹⁵ Allen R, Cwiak C. Contraception for women with medical conditions. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.