ADOLESCENT GYNECOLOGY Abnormal Uterine Bleeding in the Adolescent Patient Nirupama K. DeSilva, MD Common Clinical Scenario: A 14-year-old fe- due to an immature hypotha- FOCUSPOINT male presents to your office with the complaint lamic-pituitary-ovarian (HPO) of menses “every 2 weeks” for the past few axis, causing anovulatory cy- months. She states that her periods started at cles and irregular bleeding.4 age 13, and after her first period she did not Before the diagnosis of imma- have another menses for 3 months. After her sec- ture HPO axis can be assumed, Many patients ond menstrual cycle, her periods started “hap- more serious disorders must complain of pening all the time.” She notes that menses be ruled out (Table).5,6 While menstrual problems sometimes come once a month, sometimes “skip there are numerous etiologies a month,” and lately have been coming twice a for abnormal uterine bleeding that actually fall month. Her menses last for 5 days, during which in the adolescent, this article within normal she changes 3 pads per day. She is in good will concentrate on the evalua- variations. health, with no medical problems or history of tion and management of DUB surgeries. Urine pregnancy test is negative. in the adolescent female. enstrual disorders are among the EVALUATION most common complaints of adoles- When an adolescent presents cents. This is in part because adoles- with the complaint of DUB, she should be asked cents and their families often have detailed questions about her menstrual history, Mdifficulty understanding what normal cycles or including the age at menarche and the timing, patterns of bleeding are and in part because duration, and quantity of her uterine bleeding. there is considerable menstrual cycle variabil- The presence of cramping and/or clots can be ity in the adolescent years.1 Regular ovulatory useful information as well. menstrual cycles occur every 21 to 35 days and Review of systems should address psychosocial last up to 7 days, with an average blood loss of stressors, weight changes, eating and exercise 25 to 69 mL.2 Many patients complain of men- habits, medications, and symptoms of hyperan- strual problems that actually fall within nor- drogenism. Family history of bleeding disorders mal variations. In the first year after menarche, and menstrual history is imperative, as is a sex- 50% of cycles are anovulatory, but 80% still fall ual history.7 in the normal range for duration. By the third Physical examination should include vital year of menarche, 95% of menstrual cycles fall signs and evaluate for signs of hyperandrogen- into this range.3 Charting the menstrual flow ism and bleeding. The Sexual Maturity Rating on a calendar can be helpful to clarify normal scale should be determined to be at the appro- versus abnormal cycles. Cycles that fall outside priate stage for the patient’s age. The nipples of the norm should be evaluated for underlying should be assessed for discharge. In most pa- pathology. tients, especially those who are not sexually ac- While there are multiple causes for abnormal tive, an internal pelvic exam is not necessary to uterine bleeding in adolescents, the most likely evaluate the pelvic anatomy. In such patients, cause is dysfunctional uterine bleeding (DUB) an ultrasound may be sufficient to evaluate for pelvic pathology. If a pelvic exam is absolutely Nirupama K. DeSilva, MD, is Assistant Professor, Department needed in cases of massive bleeding, trauma, of Obstetrics and Gynecology, University of Oklahoma School or suspected congenital anomolies, one can be of Community Medicine, Tulsa. performed under anesthesia. Sexually active Follow The Female Patient on and The Female Patient | VOL 35 JULY 2010 25 ADOLESCENTGYNECOLOGY Abnormal Uterine Bleeding in the Adolescent Patient TABLE. Causes of Abnormal Uterine Bleeding in the Adolescent5,6 Anovulation • Progestins (eg, Depo-Provera) Bleeding associated with pregnancy • Spironolactone • Abortion (threatened or incomplete) Ovarian failure • Ectopic Pathology involving the reproductive tract • Retained products of conception • Endometrial hyperplasia/carcinoma Coagulation defects • Endometrial polyp Congenital malformation of the uterus Systemic diseases Endometriosis • Adrenal insufficiency • Chronic renal disease Exercise-induced amenorrhea • Cushing syndrome Hyperprolactinemia • Diabetes mellitus Infections • Late-onset congenital adrenal hyperplasia • Condyloma of the cervix/vagina • Liver disease • Pelvic inflammatory disease • Polycystic ovary syndrome • Vaginitis/cervicitis (trichomonas/gonorrhea) • Systemic lupus erythematosis Medications • Thyroid abnormalities • Anticoagulants Trauma • Chemotherapy drugs • Danazol Tumor • Exogenous steroids • Ovarian cyst or tumor • Oral contraception (eg, midcycle bleeding • Sarcoma botryoides or continuous use) females should receive testing for sexually trans- antigen, and plasma VWF activity (ristocetin mitted infections. cofactor activity). Laboratory work-up of adolescents with ab- As well, in any patient with abnormal uterine normal uterine bleeding should include a preg- bleeding, thyroid function tests should be con- nancy test, regardless of whether the history sidered, as this can be a common cause of ab- reveals sexual activity. Once pregnancy has normal uterine bleeding. In patients with head- been ruled out, the practitioner should con- aches or nipple discharge, prolactin testing is sider additional lab work to rule on other diag- warranted. In those with signs of polycystic noses in the differential based on the present- ovary syndrome or insulin resistance, the practi- ing signs and symptoms. A complete blood tioner should consider appropriate lab testing, count may be helpful to evaluate for anemia. including testosterone, insulin, and glucose ACOG recommends that all patients younger levels. Evaluating the adrenal glands to look for than 18 who present with abnormal uterine abnormalities in suspected cases may be war- bleeding be screened for coagulation disor- ranted as well. ders, particularly von Willebrand disease, as this disorder has a prevalence of 1% and is the MANAGEMENT most common disorder that causes menorrha- After other diagnoses have been ruled out, the gia at menarche.1,6 Screening for such disorders management of DUB can occur as an outpatient should include a partial thromboplastin time, in the majority of cases. Occasionally, however, prothrombin time, and assessment of platelet hospitalization is required due to hemodynamic function, plasma von Willebrand factor (VWF) instability. 26 The Female Patient | VOL 35 JULY 2010 All articles are available online at www.femalepatient.com. DeSilva Mild Uterine Bleeding (Hgb >12 mg/dL) Severe Uterine Bleeding/Menorrhagia Management of mild abnormal bleeding consists (Hgb <10 mg/dL) of observation and reassurance. If hemoglobin Excessive menstrual bleeding is diagnosed as (Hgb) concentration is normal (>12 mg/dL), girls menses more often than every 21 days or bleed- with mild DUB should be asked to keep a men- ing resulting in a loss of more than 80 mL of strual calendar and can be given the option to blood.2 Menstrual flow requir- avoid treatment with hormonal therapy. They ing changes of menstrual FOCUSPOINT should follow up in 3 to 6 months, unless bleed- products every 1 to 2 hours is ing becomes more severe, in which case they considered excessive, espe- should be seen acutely. cially if the flow lasts longer Menstrual flow than 7 days.1 While it may be requiring changes Moderate Uterine Bleeding (Hgb 10-12 mg/dL) due to anovulation, this type of of menstrual Moderate DUB is characterized by moderately bleeding may be associated prolonged or frequent menses every 1 to 3 with a bleeding disorder, and products every weeks.8 Menstrual flow is moderate to heavy. work-up for this should ensue. 1 to 2 hours is con- Mild anemia (Hgb 10-12 mg/dL) is often present Hospitalization is necessary sidered excessive, but without signs of hypovolemia or hemody- for patients who are hemody- namic instability. Moderate DUB can usually be namically unstable, who have especially if the managed in the outpatient setting. The treatment low Hgb concentration (<7 mg/ flow lasts longer typically involves hormonal therapy to stabilize dL), or who have symptomatic than 7 days. endometrial proliferation and shedding. The anemia.8 Heavy active bleeding choice of agent(s) depends, to some extent, upon and Hgb lower than 10 mg/dL how heavily the patient is bleeding.9 Girls with are also considered by some to moderate DUB should be provided with iron be an indication for hospitaliza- supplementation. tion. If the Hgb is between 8 and 10 mg/dL, and There is a paucity of data from randomized the patient is hemodynamically stable, and the trials regarding the treatment of DUB in adoles- patient and family are reliable and can maintain cents. Nonetheless, there are a variety of regi- close telephone contact, home management may mens that appear to be equally effective. Pa- be possible with daily monitoring. tients who have complaints of heavier bleeding The need for blood transfusion should be in- may have a better response to oral contracep- dividualized, and it should be administered as tives (OCs) that have a combination of estrogen deemed necessary by the clinician based on and progestin rather than to progestin-only the patient’s initial blood count, amount of preparations, as estrogen provides hemostasis. bleeding, and any other comorbidities. Thus, one option is to use monophasic contra- Girls who require hospitalization