Substance use disorder: contraceptive options counseling

What’s New in Contraception?

Contraceptive Technology Conference!

Biologic sexism of STIs

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding


Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm


Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception New and Improved

Menstrual exacerbation of other medical conditions
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.