It's that time of the month: Menstrual suppression among adolescents and young adults with cancer and quality of life

Abstract Introduction: Adolescents and young adults (AYAs) with cancer have significantly worse health related quality of life (HRQL) than their peers. Menstrual problems occur in up to 80% of adolescents, and heavy menstrual bleeding (HMB) is associated with decreased HRQL in AYAs in the general population. However, this has not been examined among AYAs with cancer, and no detailed guidelines exist for this population. AYA females receiving myelosuppressive chemotherapy are at increased risk for abnormal uterine bleeding due to thrombocytopenia and coagulopathy. While medical intervention can be used to prevent severe blood loss and further exacerbation of treatment-related anemia by suppressing menses, this is used inconsistently. (Wolfson/Arbuckle, JCO-OP 2023) The validated Menorrhagia Impact Questionnaire (MIQ) evaluates the effect of HMB on women's self-assessment of menstrual blood loss, its effect on daily activities, and the meaningfulness of any observed changes in HRQL. Methods: Newly diagnosed or newly relapsed 15-39yo AYAs with cancer were recruited from pediatric and adult oncology services at University of Alabama at Birmingham if their treatment plan included chemo/immunotherapy. Participating AYAs completed baseline questionnaires within 6 months of starting cancer therapy. Those assigned female at birth were presumed to be post-menarchal due to the inclusion criteria for age. Those who reported menses within the prior 30 days also completed the MIQ. MIQ scores range from 4 to 21, with higher scores indicating worse menstrual-related quality of life (MQL). For the purposes of analysis, patients were stratified by self-reported prescription for a menstrual suppression agent. Patients diagnosed with leukemia and sarcoma were presumed to have more myelosuppressive chemotherapy based on standard of care regimens, thus compared to other diagnoses. Descriptive statistics were used to summarize data. Results: Among participating female AYAs (n=55) 65% had a menstrual period in the prior 30 days. An agent for menstrual suppression was prescribed for 40% (n=22) of female AYAs including 12 of 20 (60%) AYAs with leukemia/sarcoma and 10 of 35 (29%) AYAs with diagnoses presumed to receive less myelosuppressive therapy (p=0.04). A period within the prior 30 days was reported by 68% of AYAs prescribed menstrual suppression and 64% of AYAs who were not. Menstrual suppression was prescribed for 40% of AYAs with public (16 of 40), or private (6 of 15) insurance (p=1.0); no uninsured patients received a prescription for suppression. HMB limited daily activities in 47% of AYAs prescribed and 57% of those not prescribed menstrual suppression (p=0.5). Overall, the mean MIQ score was 8.5 (SD=3.8). There was no statistically significant difference between mean MIQ scores among AYAs prescribed (mean=8.6, SD=4.1) and not prescribed (mean=8.5, SD=3.6; p=0.9) menstrual suppression or between more myelosuppressed AYAs with leukemia/sarcoma (mean=9.6, SD=4.1) and those less myelosuppressed with other diagnoses (mean=8.5, SD=3.6; p=0.2). Conclusions: Less than half of our cohort was prescribed menstrual suppression. Acknowledging our limited sample size and statistical power, MQL did not vary significantly by menstrual suppression status. While practice varies with respect to prescribing menstrual suppression, these findings suggest that not all patients may require suppression, as a third of patients did not have a period within the prior month regardless of menstrual suppression. Absence of a menstrual cycle in the group without menstrual suppression may be attributable to several physiologic derangements that accompany adolescence and cancer, including recent menarche and inconsistent menstrual cycles. Furthermore, less myelosuppressive chemotherapy regimens may not result in sufficient thrombocytopenia to benefit from menstrual suppression. Lack of insurance may have posed a barrier to care, as no uninsured patients received a prescription for menstrual suppression. HMB limited daily activities in AYAs regardless of menstrual suppression medication, suggesting both missed opportunities to improve HRQL and/or ineffective suppression. For AYAs receiving cancer therapy, neither the optimal agent for menstrual suppression nor the patient groups who would benefit most have yet been established. Further work is needed to help develop clear disease-specific guidelines regarding optimal approaches to menstrual suppression.