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Abnormal Uterine Bleeding in AdolescentsMaria C. Monge, MD
Director of Adolescent MedicineDell Children’s Medical Center
UTSW-Austin Pediatrics Residency ProgramLone Star Circle of Care
Disclosures
• I have no relevant financial disclosures.
Objectives
• 1. Define abnormal uterine bleeding (AUB) in an adolescent.
• 2. Discuss possible etiologies of AUB in an adolescent and use these in consideration of the the initial outpatient workup of AUB.
• 3. Identify initial outpatient management strategies for adolescents with AUB.
CASE – MADELINE
Madeline
• Madeline is a 12 year old who comes to your office after she felt lightheaded at school.– Mom called and triage nurse said to bring her in. – Mom told the nurse that Madeline has had
menstrual bleeding for more than 1 week and has been feeling more tired than usual for the past month.
Madeline
• Review of records before she arrives– Healthy, on no medications– Growth and development normal• 50% BMI• At last WCC had not started menstruating, but had
SMR3 breasts and pubic hair
– Family history unremarkable
NORMAL MENSES
Normal Menses
• Menarche: 2.3y after pubertal initiation– Range 1-3 years
• Cycle length: 21-42 days (beginning to beginning)– Should be regular by 2-2.5 years– Cycles outside of 20-45 days should be considered
abnormal even in adolescents • Duration: 3-7 days• Average blood loss: 30 mL/cycle– Can be 20-80mL
Normal Menses
Anovulatory Cycles
• 55-82% of adolescents take up to 24 months after menarche before having regular ovulatory cycles– Adolescents with later onset of menarche have longer intervals
until cycles become ovulatory– Immaturity of HPO axis
• Having an occasional ovulatory cycle stabilizes endometrial growth and allows for complete shedding
Madeline
• On arrival to office -- History– In the midst of her 3rd menstrual period• First one about 4 months ago and was light, lasted 5
days; Second one about 2 months ago and was moderate flow lasting 7 days
– Started 8 days prior– Soaking pads every 1-2 hours
How do you quantify bleeding?
• Proposed screening questions– Period lasting > 7 days– Feeling of “flooding” or “gushing” most cycles– Activities limited by periods– Bleeding “problem” after dental extraction,
surgery or delivery/miscarriage– Family history of bleeding disorder
Madeline – Additional details
• ROS: feeling tired, maybe easy bruising but not sure, no acne or hirsuitism
• Medications: None• Family History: Mom menarche age 13 and
was irregular for 1-2 years• Social history: Lives with Mom, in 6th grade,
has a boyfriend but no sex, no trauma, no foreign bodies in vagina
DIFFERENTIAL DIAGNOSIS
Differential for abnormal bleeding
• Anovulatory uterine bleeding
• Endocrine disorders• Bleeding disorders• Pregnancy-related
complications• Infection• Hormonal contraception• Use of IUDs• Medications
• Vaginal, cervical or uterine carcinoma, sarcoma, polyps
• Cervical hemangioma• Congenital uterine
abnormalities• Vaginal lacerations,
trauma• Endometriosis• Foreign body
What is on our differential for Madeline?
• Systematic approach• Consider pertinent history and physical
What is on our differential for Madeline?
• Systematic approach– Prolactinoma– Thyroid Disease– Cushings, CAH– PCOS, Anovluation,
Pregnancy, POI, Trauma, Infection, Polyp
– Bleeding Disorder
EXAM CONSIDERATIONS
Exam
• Key points– Vitals , Height, Weight, BMI– Features of endocrinopathies
• Androgen excess• Cushingoid • Thyroid
– Other signs of bleeding– GU exam
• Minimum is external• Pelvic exam-most girls who have used tampons can
tolerate a 1 finger digital exam to check for foreign bodies
Madeline - Exam
• Vital Signs: BP 98/66 HR 72 T 98.4 BMI 75th%• Gen: slightly pale and anxious-appearing• Neck: no thyroid enlargement• CV: soft SEM at RUSB• Chest: SMR4 breast• Abd: soft, NT/ND, no striae• GU: SMR 4 pubic hair, external exam without evidence
of trauma, +bleeding from vagina• Skin: no hirsuitism, acne, acanthosis, petechiae,
bruising
Any changes to the differential?
• Anything move up or down the list?
LABORATORY EVALUATION
Laboratory Evaluation
• CBC with differential• B-hcg (sensitive urine or serum)• TSH, free T4• Type and Screen• FSH, LH, prolactin, free/total T, DHEA-S• PT/PTT, von Willebrand panel• GC/CT testing
Madeline - Results
• CBC: Hemoglobin 10.4 g/dL, remainder normal
• Urine hcg: negative• TSH: 255 mIU/L, T4 0.5 mcg/L• Von Willebrand Panel: – VW Factor 90% (50-160 normal)– Factor XIII 142% (70-170 normal)
A note about VWF screening
• Many factors impact VWF levels– Ideal to test off of hormones or on Day 7 of
placebos• VWD <30% activity now considered diagnostic– 30-50% is “low von Willebrand factor”
• Consider screening as not uncommon in adolescents with menorrhagia– Estimates vary widely in literature with many
suffering from selection bias
Role of imaging?
• Consider if:– Unable to do pelvic exam– Prolonged bleeding despite treatment– Pelvic mass or uterine anomaly suspected
Next steps?
• Stop bleeding• Treat underlying condition (if applicable)
Key points for all patients
• All patients should keep a menstrual calendar• Ensure iron stores are addressed, even if Hgb
normal. – Patients typically need several months of oral
iron to replete stores
HORMONAL TREATMENT OF BLEEDING
Recommended choice of OCPs
• Off-label use• Monophasic• Potent progestin– Norgestrel (0.3mg) • Ex. Lo/Ovral, Low-Ogestrel, Cryselle
– Levonorgestrel (0.15mg)• Ex. Nordette, Levlen, Levora, Portia
Note: Naming brand names does not imply endorsement of a particular product
Treatment depends on current bleeding and Hgb
• Mild– Menses slightly prolonged or cycle slightly more
frequent – Normal hemoglobin
• This can be distressing to patients and families• May observe for several cycles– Iron supplementation– Naproxen or Ibuprofen
• Anti-prostaglandins have been reported to decrease blood loss
• May consider treatment with OCP or progestin
Treatment depends on current bleeding and Hgb
• Moderate– Menses >7d or cycle frequency <3 weeks and mild anemia
(Hgb 10-11g/dL)• If patient not bleeding significantly at time of visit and
is not already on hormonal therapy can start with 1 pill daily
• If patient with moderate bleeding at time of visit, 1 pill BID until bleeding stops, then daily for total of 21 days– Continue cyclic pills or may do continuous
• Follow Hgb as needed– Consider continuing pills at least until Hgb normal (min 3-6
months)
Treatment depends on current bleeding and Hgb
• Severe– Ongoing heavy bleeding with moderate anemia (Hgb 8-
10g/dL)• If bleeding is slowing and Hgb >9 g/dL
– Can start with BID pills (see moderate)• If bleeding not slowing
– 1 pill q6h for 2-4 days• prn anti-emetic 2h before pill
– 1 pill q8hx 3 days– 1 pill q12h for at least 2 weeks
• Follow serial Hgb closely• Consider inpatient admission if concern for patient/family
reliability
Treatment depends on current bleeding and Hgb
• Severe– Ongoing heavy bleeding, Hgb ≤ 7g/dL, Orthostatic
vital signs– Admit for inpatient management– Notes• Decision to transfuse not based solely on number• Most patients can be managed with OCPs• D&C rarely indicated
What if patient has contraindication to estrogen?
• Medroxyprogesterone– Short courses in mild bleeding– Cyclic therapy if need ongoing
• Norethindrone acetate– Short courses in mild bleeding– Cyclic therapy– Continuous menstrual suppression
• LNG-IUS
INDICATIONS FOR REFERRAL
When should referral be considered?
• To ER– Symptomatic anemia– Vital sign abnormalities
• To Adolescent Medicine/Reproductive Endocrinology– OCP complications or decisions– Bleeding difficult to control (breaking through)– Secondary cause identified
TAKE HOME POINTS
Conclusions
• Remember what is “normal”• Differential broad• History is important– Menstrual history as a “vital sign”
• CBC to guide treatment• Different treatment options exist
Thank you!
Contact information:
Maria C. Monge, MDDirector of Adolescent MedicineUTSW-Austin Pediatrics Residency [email protected]