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.

Answer: 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.

Dear Dr. Roach: I’m a 65-year-old, overweight white woman. I recently had a DEXA scan, and based on the results, my general physician prescribed Fosamax for osteopenia.

The first dose created a horrible reaction two days after ingestion, with severe pain in both my arms, neck, and legs. I was in absolute agony for two days, then it cleared up. With the next dose a week later, I hesitated but still decided to take it. Two days later, the reaction hit me again, only worse. I could barely walk, and my energy was so low. I spent four days in bed, except to cry when heading to the bathroom. I had not taken my Lasix prescription for those four days, as I could barely make it to the bathroom.

I contacted my doctor, and she discontinued Fosamax. She’s referring me to a rheumatologist. I read that this drug has all my symptoms, plus more, listed under the severe reaction warning. I will not take it again. Also, a friend told me that this drug is not effective for osteoporosis after more than 20 years of drug tests and I should not have been prescribed this drug, since I have osteopenia, not osteoporosis. Your thoughts? — C.W.

Answer: Alendronate (Fosamax) is in the class of drugs called bisphosphonates. These are powerful drugs that should not be prescribed lightly. They do have the potential for severe side effects. Severe musculoskeletal pain can occur days or months (sometimes years) after starting the medicine. The Food and Drug Administration has advised prescribers to discuss this possibility with their patients so that the drug can be stopped immediately if it occurs. There are other options available if the person really needs treatment.

Your friend is half right. Powerful drugs like Fosamax are usually not indicated in people who have low bone mass (osteopenia) without osteoporosis. However, a history of a fragility fracture (breaking a bone from minor trauma that isn’t expected to cause a fracture) can make the diagnosis of osteoporosis, even if the bone density isn’t in the usual osteoporotic range. A person can have a high risk of fractures for other reasons, and a clinical tool called the FRAX score helps clinicians identify those who might benefit from treatment.

But your friend is also half wrong. When used appropriately, Fosamax and other bisphosphonate drugs are effective at reducing the risk of fractures. A vertebral body fracture can cause years of pain and can be avoided easier, while a hip fracture can be devastating. So, there are very good reasons to prescribe these medicines.

Finally, let me warn readers against complacence in treatment with these drugs. They may be appropriately prescribed for a high-risk person, but most people should not stay on this drug forever. Follow-up DEXA scans should guide therapy, and after three to five years, a conscious decision should be made whether to continue therapy.

Readers who have been on these drugs for more than five years and haven’t had careful follow-ups on their results should ask their doctors whether they still need to be taking them.