Dear Dr. Roach: I am a 47-year-old female who has suffered from an irregular period for the past 22 years. I was prescribed combination birth control pills, which did a good job of controlling and regulating my period for 20 years.
At my annual checkup three years ago (at age 44), I told my OB-GYN that I had what sounded like a migraine aura, but without a headache. My OB-GYN immediately stopped the combination birth control pills (after noting my age). I do not qualify for an IUD because of a split uterus, so she suggested a hysterectomy, which I refused. She then put me on progesterone birth control pills. I have since been on three different types of progesterone pills that have caused more problems than benefits, and I have not had my period regulated for the past two years.
My question is, any there other things I can do to control my period other than the treatments I mentioned above? I have had several tests, scans, and a biopsy done, and all have come out negative for any problems. Is there somehow a way at my age that I can get back on the combination pills until menopause? I want to live a normal life instead of missing work and being shuttered in my home for days because of a heavy period.
J.L.
Your gynecologist is concerned that you might have a stroke. Women who have migraine with aura are at a much greater risk for having a stroke while on estrogen. Published rates of this risk range from a 50% to 820% increase in risk. This is particularly important for women over 45. The guidelines are clear that the risk is unacceptable for women with aura to receive combination oral contraceptives.
It is certainly possible to have migraine aura without getting a headache (sometimes called a “migraine equivalent” or “acephalic migraine”). Nearly everyone with this does get a painful migraine at some point. Although there isn’t a lot of guidance on this, my opinion is that the risk of a stroke would also be elevated for a woman with aura but without a headache who is taking oral contraceptives.
However, it is my experience that what people describe as aura isn’t always accurate. A migraine aura has “positive” features (bright lines, shapes or objects) as well as “negative” features (loss of vision). An aura typically develops slowly, over 5 minutes or more, and is completely gone within an hour. Neurologists are the experts in getting the precise history necessary to make the diagnosis of an aura, and this diagnosis has real meaning for you. If the neurologist feels that this is not aura, then you should be able to go back to your original treatment.
If this is not an option, and you can’t use an IUD and don’t want surgery, one other option I have read about but never used is tranexamic acid, which is indicated for cyclic, heavy menstrual bleeding. You should ask your gynecologist if this is a potential therapy for you. This drug has several side effects, and I don’t prescribe it, since it needs to be prescribed by an expert — meaning a gynecologist.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
