Menstrual management considerations in the space environment

Management of menstruation, pregnancy prevention, and mitigation of gynecologic-related pathology in the space environment with or without the use of hormonal modalities requires thorough counseling and complex decision-making. Factors that must be considered by astronauts and their physician teams range from desirability of contraception and/or menstrual suppression to weighing the risk and benefit profiles of various formularies of progesterone or combination estrogen and progesterone-containing hormonal modalities on various pathologies, including abnormal uterine bleeding, ovarian cyst production and risk of torsion, bone mineral density and osteopenia, venous thromboembolism, and cancer. Simultaneously, the choice to use or abstain from one of these modalities may also impact onboard mass, volume, and engineering considerations relating to stowage of onboard resources and sanitation products as well as impacting the design or function of waste management systems. While significant gynecological morbidity has not been reported during spaceflight, the objective of this review is to untangle these interrelated complexities to empower astronauts, physician and pharmacy teams, and engineering teams to enable the development of systems and protocols that support astronaut autonomy in reproductive decision-making and optimally mitigate future gynecologic risk.