How to deal with asthma that worsens during periods?

Question

Hello doctor,

My 19-year-old daughter has had asthma since childhood, but her symptoms have worsened significantly since starting college and beginning regular menstrual cycles. Her peak flow drops from a baseline of 400 L/min to around 250 L/min during her periods. During menstruation, she needs her Albuterol inhaler four to five times daily, compared to just twice a week otherwise.

Her pulmonologist increased her controller to Fluticasone-Salmeterol 250/50 twice daily, but she is still having breakthrough symptoms. Last month, the college health center prescribed Prednisone 40 mg for five days, which helped, but we are concerned about frequent steroid use.

Recent spirometry showed an FEV1 of 75 percent predicted, down from her usual 90 percent. She is also experiencing severe PMS symptoms. Her gynecologist suggested hormonal birth control, but we are hesitant, as I had worsening asthma with it in the past.

She now avoids sports due to exercise-induced symptoms, and her roommate reports loud wheezing at night, especially during her period.

Are there specific asthma treatments that are more effective for hormonally-triggered symptoms? We are also considering a referral to an allergist-immunologist for further evaluation. Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

I read your query and can understand your concern.

This is a challenging but fairly common situation; many women experience worsened asthma (a chronic condition where the airways become inflamed) control around their menstrual cycles, often referred to as perimenstrual asthma (a type of asthma that worsens around the time of menstruation due to hormonal fluctuations). You are doing the right thing by taking a proactive, comprehensive approach. Here is how her case can be addressed:

Understanding the issue:

Hormonal fluctuations, especially changes in estrogen and progesterone, can increase airway inflammation and sensitivity. Your daughter’s drop in peak flow (from 400 to 250 L/min), reduced FEV1 (75 percent predicted), and frequent Albuterol use indicate poor asthma control during her period, despite being on Fluticasone-Salmeterol. Although Prednisone helped, it is not a long-term solution.

Treatment considerations

1. Optimize baseline control:

Ensure proper inhaler technique and adherence.
Consider stepping up her controller therapy temporarily or permanently (for example, higher ICS (inhaled corticosteroid) dose or add-on therapy).

2. Hormonal management:

Hormonal birth control can help stabilize hormonal swings.
If you are concerned about side effects, options include a low-dose combined oral contraceptive (COCP), a Progestin-only pill, or an IUD (intrauterine device).
The gynecologist and allergist should coordinate care.
Continuous hormonal therapy to skip periods may also reduce asthma flares.

3. Asthma boost during menses:

A temporary increase in ICS dose around her period may help.
Add-on Montelukast (leukotriene receptor antagonist) may reduce perimenstrual symptoms.
Vitamin D and magnesium supplementation might have additional benefits.

4. Specialist referral:

Seeing an allergist-immunologist is a good next step. Kindly do the following:

Allergy testing.
Evaluation for biologics (for example, for eosinophilic or severe asthma).
Tailored immunotherapy, if indicated.

5. Supportive measures:

Address severe PMS (premenstrual syndrome) to reduce inflammation and stress (for example, SSRIs (selective serotonin reuptake inhibitors), calcium, and lifestyle changes).
Nighttime wheezing may point to poorly controlled asthma and requires close monitoring.
Pre-exercise bronchodilators and optimal baseline control can help her return to sports.
Avoid overuse of Albuterol to prevent reduced effectiveness.

Next steps:

Trial hormonal therapy (with gynecology input).
Adjust asthma meds before or during her period.
Consult an allergist for further evaluation and advanced treatment.
Continue peak flow tracking and symptom logs.

I hope this helps.

Please revert in case of further queries.

Thank you.