Prevention of Menstrual Bleeding in thrombocytopenic women

  All females who are menstruating should be given some form of suppressive treatment to prevent bleeding during myeloablative chemotherapy or during severe thrombocytopenia. There are a number of options available. Treatment should be started after the woman has finished a menstrual cycle. Options include the following:

Leuprolide Acetate (Lupron): Lupron is the best option for all patients but especially those with a history of breast cancer. Luprolide must be started the month prior to chemotherapy. It is expected that the patient will have a withdrawal bleed two weeks after the drug is given. The patient then should have their menstrual cycle suppressed until leuprolide is discontinued. Dosing options are as follows:

Leuprolide Acetate (Lupron) 1 mg IV or SQ daily throughout chemotherapy until platelets > 50,000.

Leuprolide Acetate (Lupron) 3.75 mg IM Q 28 days until platelets > 50,000.

Leuprolide Acetate (Lupron) 11.25 mg IM Q 3 months or until platelets > 50,000.

If the patient can not start this therapy the month before undergoing chemotherapy leuprolide can be given with an oral contraceptive during the period after chemotherapy to prevent withdrawal bleeding which is expected two weeks after starting leuprolide. Leuprolide causes hot flashes. A small dose of Prempro (conjugated estrogen 625 mcg/ medroxyprogesterone 2.5 mg) can be given if the patient is symptomatic.

Oral contraceptives: Patients who are still menstruating will take oral contraceptives to prevent pregnancy and to suppress menses. Lo-Ovral (30 mcg ethinyl estradiol) one tablet PO qd should be started a month prior to chemotherapy. The patient will not take the placebo week of pills. If bleeding occurs the patient will start Ovral (50-mcg-ethinyl estradiol) one tablet PO QD. Once bleeding has stopped the patient may resume Lo-Ovral. Once the platelet count is greater than 50,000 the patient may stop oral contraceptives unless further chemotherapy is planned in the near future.

Nafarelin Acetate: (Synarel) An alternative for suppression of menses. This drug needs to be started a month before chemotherapy.

Nafarelin Acetate 2 sprays (200mcg) to nostril BID. Alternate nostril with each dose. Stop once the platelet count is > 50,000.

For severe bleeding consult Gynecology for assistance in management.

     References:

Ghalie, R., Porter, C., Radwanska, E., Fitzsimmons, W., Richman, C., & Kaizer, H. (1993) Prevention of Hypermenorrhea with Leuprolide in Premenopausal Women Undergoing Bone Marrow Transplantation. American Journal of Hematology. 42: 350-353.

Laufer, M.R., Townsend, N. L., Parsons, K.E., Brody, K.A, Diller, L.R., Emans, S. J. Guinan, E. C. (1997). Inducing Amenorrhea During Bone Marrow Transplantation. The Journal of Reproductive Medicine, 42: 537-541.
 

Reviewed January 2005