Benefits and commonly seen limitations of available therapeutic strategies for HMB in adolescents
| Therapeutic strategy . | Benefits . | Limitations . |
|---|---|---|
| Combined oral contraceptives | Easy to titrate dose and cycling; reduces menstrual irregularity, dysmenorrhea, and acne | Daily compliance is particularly challenging for adolescents; nausea; cannot be used by patients with thrombosis, thrombophilia, migraine with aura |
| Transdermal contraception | Requires only a once-per-week patch change; reduces menstrual irregularity, dysmenorrhea, and acne | Adolescents may have increased concern with visibility in locker rooms and during swimming; cannot be used by patients with thrombosis, thrombophilia, migraine with aura |
| Vaginal ring | Discrete; requires removal and insertion only once per month; reduces menstrual irregularity, dysmenorrhea, and acne | Adolescents may have discomfort with idea of vaginal insertion; cannot be used by patients with thrombosis, thrombophilia, migraine with aura |
| Levonorgestrel-containing intrauterine system | Discrete; effective for 3 to 5 years, depending on brand; many patients have a large reduction or complete cessation of menstrual bleeding; most effective for contraception; excellent safety profile for patients with increased risk of thrombosis | Requires pelvic examination for insertion; patients often have irregular bleeding for 4 to 6 months after insertion; higher upfront costs |
| Progestin-only pills (mini-pills) | Safe for women with estrogen contraindications | Requirement for strict adherence in timing of daily dose difficult for adolescent schedules; breakthrough bleeding a common cause for discontinuation |
| Norethindrone | Many patients experience complete cessation of menstrual bleeding | Weight gain and moodiness are common adverse effects, especially at higher doses (7.5 mg or 10 mg per day) |
| Depot medroxyprogesterone acetate | Safe for women with estrogen contraindications; discrete; requires injection only once every 12 weeks; many patients have substantial reduction in menstrual bleeding | Requires intramuscular injection; reinjection must be timely; risk of decreased bone density; although weight gain >2 kg not supported by available evidence, some patients do experience weight gain, and there is fear regarding this adverse effect in the adolescent community |
| Progestin-only implantable | Discrete; lasts for 3 years; highly effective contraceptive; safe for women with estrogen contraindications | Requires minor procedure for insertion; higher upfront costs; breakthrough bleeding a common cause for discontinuation |
| Tranexamic acid | Option for families who do not want to use a hormonal strategy; taken only during menses; minimal adverse effect profile | Does not provide cycle regulation; not indicated for dysmenorrhea; 3-times-per-day dosing is challenging for adolescents |
| Nasal desmopressin | Option for families who do not want to use a hormonal strategy; taken only during menses | Does not provide cycle regulation; not indicated for dysmenorrhea; because of tachyphylaxis, can be used for only 2 to 3 days during menses; facial flushing and headaches are commonly reported adverse effects |
| Therapeutic strategy . | Benefits . | Limitations . |
|---|---|---|
| Combined oral contraceptives | Easy to titrate dose and cycling; reduces menstrual irregularity, dysmenorrhea, and acne | Daily compliance is particularly challenging for adolescents; nausea; cannot be used by patients with thrombosis, thrombophilia, migraine with aura |
| Transdermal contraception | Requires only a once-per-week patch change; reduces menstrual irregularity, dysmenorrhea, and acne | Adolescents may have increased concern with visibility in locker rooms and during swimming; cannot be used by patients with thrombosis, thrombophilia, migraine with aura |
| Vaginal ring | Discrete; requires removal and insertion only once per month; reduces menstrual irregularity, dysmenorrhea, and acne | Adolescents may have discomfort with idea of vaginal insertion; cannot be used by patients with thrombosis, thrombophilia, migraine with aura |
| Levonorgestrel-containing intrauterine system | Discrete; effective for 3 to 5 years, depending on brand; many patients have a large reduction or complete cessation of menstrual bleeding; most effective for contraception; excellent safety profile for patients with increased risk of thrombosis | Requires pelvic examination for insertion; patients often have irregular bleeding for 4 to 6 months after insertion; higher upfront costs |
| Progestin-only pills (mini-pills) | Safe for women with estrogen contraindications | Requirement for strict adherence in timing of daily dose difficult for adolescent schedules; breakthrough bleeding a common cause for discontinuation |
| Norethindrone | Many patients experience complete cessation of menstrual bleeding | Weight gain and moodiness are common adverse effects, especially at higher doses (7.5 mg or 10 mg per day) |
| Depot medroxyprogesterone acetate | Safe for women with estrogen contraindications; discrete; requires injection only once every 12 weeks; many patients have substantial reduction in menstrual bleeding | Requires intramuscular injection; reinjection must be timely; risk of decreased bone density; although weight gain >2 kg not supported by available evidence, some patients do experience weight gain, and there is fear regarding this adverse effect in the adolescent community |
| Progestin-only implantable | Discrete; lasts for 3 years; highly effective contraceptive; safe for women with estrogen contraindications | Requires minor procedure for insertion; higher upfront costs; breakthrough bleeding a common cause for discontinuation |
| Tranexamic acid | Option for families who do not want to use a hormonal strategy; taken only during menses; minimal adverse effect profile | Does not provide cycle regulation; not indicated for dysmenorrhea; 3-times-per-day dosing is challenging for adolescents |
| Nasal desmopressin | Option for families who do not want to use a hormonal strategy; taken only during menses | Does not provide cycle regulation; not indicated for dysmenorrhea; because of tachyphylaxis, can be used for only 2 to 3 days during menses; facial flushing and headaches are commonly reported adverse effects |