To Bleed...

Christina Davis-Kankanamge Pediatric and Adolescent Gynecology

Learning Objectives

• Define abnormal uterine bleeding • Reasons for menstrual suppression • Options for menstrual suppression

1 Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood.

Abnormal Uterine Bleeding

“outside of normal volume, duration, regularity, or frequency is considered abnormal uterine bleeding” excessive blood loss should be based on the patient’s perception

Persistent anovulation is most frequent in the adolescent age group identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood

2 Menstrual Bleeding

Normal Abnormal • Change of hygiene items every 1-2h • 3-6 hygiene items a day • Lasting more than 7d • Shorter interval than q21d or longer • Every 21-45d than 45d • <7d • Occur 90d apart even for one cycle • Are heavy and associated with excessive bruising/bleeding or a family history of bleeding d/o

Menstrual Bleeding

Normal Abnormal • 3-6 hygiene • Change of hygiene items every 1-2h items a day • Lasting more than 7d • Every 21-45d • Shorter interval than q21d or longer than 45d • <7d • Occur 90d apart even for one cycle • Are heavy and associated with excessive bruising/bleeding or a family history of bleeding d/o

3 … Or Not to Bleed

Chimsom T. Oleka, MD, FACOG Pediatric and Adolescent Gynecology

4 ontact with the monthly flux of women turns new wine sour, makes crops wither, kills Cgrafts, dries seeds in gardens, causes the fruit of trees to fall off, dims the bright surface of mirrors, dulls the edge of steel and the gleam of ivory, kills bees, rusts iron and bronze, and causes a horrible smell to fill the air. Dogs who taste the blood become mad, and their bite becomes poisonous as in rabies. –Pliny the Elder, “Naturalis Historia: A Selection”

1st Century AD

Attitudes Toward

• Men and younger adults report more negative attitudes • The worse the period is, the more negative the attitude • It has been argued that women believe menstruation to be a source of “social stigma” – Work hard to conceal the fact that they are menstruating – Shame and secrecy – Fear that the menstrual status will be discovered is perpetuated by menstrual product advertisements and education

Brooks-Gunn & Ruble (1980). Geller, Harlow et al (1999). Golub (1992). Christler & Johnston-Robledo (2000). Morse & Kieren (1993). Kowalski and Chapple (2000). Couts & Berg (1993)Kissling (1996) McKeever (1984)

5 • “Women, as members of a culture that sexualizes or objectifies their bodies, are motivated to distance themselves or dissociate from bodily functions, such as menstruation, that are deemed incompatible with their sexual attractiveness or desirability.”

• The higher the level of self-objectification, the more likely the negative attitudes and emotions regarding menstruation.

Roberts , T.A (2004) “Female trouble: The menstrual self-evaluation scale and women’s self-objectification” Psychology of Women Quarterly

• Controversial • De-popularized monthly menses

“While menstruation may be culturally significant, it is not medically meaningful.”

1999

6 Menstrual The use of contraceptive methods to eliminate Suppression or decrease the frequency of menses

• Prescribed for adolescents to: – Treat menstrual disorders – Accommodate patient preference • There is no medical indication for menstruation to occur monthly 1/3rd of adolescents • Menstrual suppression is becoming who use COCs do so more common among contracepting for non-contraceptive adolescents reasons

Kantartzis, K.L., Sucato, G.S. (2013) “Menstrual Suppression in the Adolescent”J Pediatr Adolesc Gynecol

Conditions Treated with Menstrual Suppression

• Patient preference • Malignancy • Menstrual-related problems • Hematologic abnormalities – - Anemia – Pelvic pain - Thrombocytopenia – - Von Willebrand disease – – • Menstrual hygiene – Ovarian cysts – Developmental delay – Physical disabilities • Chronic conditions with cyclic exacerbations – Epilepsy – Migraines or other headaches – Asthma Kantartzis, K.L., Sucato, G.S. (2013) “Menstrual – Cystic fibrosis Suppression in the Adolescent”J Pediatr Adolesc Gynecol – Porphyria

7 Methods of Menstrual Suppression: Combined Hormonal Contraception

Combination Oral Contraceptive Pills • 42, 63 or 84 days of continuous • Breakthrough bleeding decreases in hormones + 7d hormone-free interval frequency with duration of continuous use • 42, 63 or 84 days of continuous hormones + 7d low dose ethinyl- – Unexpected bleeding days decrease with frequently scheduled hormone-free -only interval intervals • Continuously until bleeding occurs, • 72% reach then begin hormone-free interval amenorrhea • Continuously through bleeding with one year of continuous use

Miller L, et al. “Continuous combination oral contraceptive pills to eliminate withdrawal bleeding: a randomized trial” Obstet Gynecol (2003)

Methods of Menstrual Suppression: Combined Hormonal Contraception

Transdermal Patch Vaginal Ring (norelgestromin 6mg/ethinyl estradiol 0.75mg) ( 120 ug/ethinyl estradiol 15 ug)

• For those that find daily pills challenging • The longer the duration of continuous hormones, the greater the number of • Use with caution unscheduled bleeding – Systemic estrogen levels are 1.6x higher than low dose COC pills • 28d vs 49d cycle – 2011 US FDA Black Box Warning: – 3 vs 5d of unscheduled bleeding increased VTE risk within the first 3 months • Rarely a first-line choice for • For those with poor pill adherence or extended cycling multiple other medications

Miller L, et al. “Extended regimens of the contraceptive vaginal ring: a randomized trial” Obstet Gynecol (2005) van den Heuvel MW, et al. “Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive” Contraception (2005)

8 Methods of Menstrual Suppression: Progestin-only Contraception

DMPA, the LNG-IUD, the Progestin-only Pill and Etonogestrel Implant • DMPA and LNG-IUD more commonly used • Initial irregular bleeding, but amenorrhea rates at one year = 46-71% – Irregular bleeding decreases with duration of use • 8% rate of LNG-IUD expulsion in adolescents; 0% risk of uterine perforation

• LNG-IUDs are supported by ACOG Those who have been counseled about irregular bleeding side-effects are more likely to continue the method

Miller L, et al. “Continuous combination oral contraceptive pills to eliminate withdrawal bleeding: a randomized trial” Obstet Gynecol (2003)

Methods of Menstrual Suppression: Progestin-only Contraception

• Progestin-only pills and etonogestrel implant are not typically recommended for menstrual suppression – Amenorrhea rate with etonogestrel implant = 14-20% – Bleeding remains irregular regardless of duration of use – 22% will have implant removed due to bleeding problems

• GnRH agonists have high-rates of amenorrhea (75-95%) within 4 weeks – Long-term consequences of inducing medical menopause in an adolescent – Reserved for short-term use – Some side-effects (hot flushes, mood lability, headaches) can be limiting

Chiusolo P. et al. “Luteinizing hormone-releasing hormone analogue: leuprorelin acetate for the prevention of menstrual bleeding in premenopausal women undergoing stem cell transplantation.” Bone Marrow Transplant (1998)

9 Management of Irregular Bleeding

APPROACHES INCLUDE • Shortening interval between scheduled withdrawal bleeds • Switching to a different method • Combining various methods How many times a • Unscheduled hormone-free interval week do you forget • Scheduled NSAIDs to take your pill? • Prescribing estrogen ‘add-back’

• Always assess compliance with daily pill-taking – Irregular bleeding is often caused by taking pills inconsistently

Kantartzis, K.L., Sucato, G.S. (2013) “Menstrual Suppression in the Adolescent”J Pediatr Adolesc Gynecol

Management of Irregular Bleeding: Unscheduled Hormone-free Intervals Continuous oral contraceptives: >7 consecutive days of unexpected bleeding = 3d hormone-free interval

Continuous vaginal ring: >5 consecutive days of unexpected bleeding = 4d hormone-free interval

Hormone-free intervals should not be used more frequently than every 3 weeks to ensure contraceptive efficacy

Sulak PJ, et al. “Attitudes and prescribing preferences of health care professionals in the United States regarding use of extended-cycle oral contraceptives.” Contraception (2006)

10 Provider and Patient Concerns

• Most gynecologist are comfortable prescribing menstrual suppression – 69% long-term use; 30% short-term use

• Adolescent health care providers have been slower to adopt this practice

• Extended regimens have no known impact on return to fertility – 86% pregnancy rate within 13 months of continuous cycle discontinuation

• No data to suggest increased risk of cancer – DMPA use for 12 consecutive months in 5 years had 2-fold higher risk of developing – Further research is needed

Li Cl. Et al. “Effect of depo-medroxoprogsterone acetate on breast cancer rik among women 20-44 years of age” Cancer (2012)

Provider and Patient Concerns: Long-term Bone Health • No consensus on ideal ethinyl estradiol dose for bone health • Adolescents using DMPA have decreased bone mineral density (BMD) – US FDA Black Box Warning: caution if use is for more 2 years • Long-term skeletal health of adolescent patients is not compromised – All studies document substantial recovery of BMD after DMPA use • 98 girls, 12-18 years old, DMPA use for up to 5 years 90% of women’s peak bone mass – Serial DEXA scans during and after DMPA use is attained by the – 16.3% had 5-8% loss in BMD; 37% had >8% loss age of 18 – Baseline BMD was recovered 2 years after discontinuation of DMPA • Lower bone loss rates noted if 1200mg daily calcium consumed ACOG does not recommend limiting DMPA use to 2 years or monitoring BMD after 2 years of DMPA use

Harel Z, et al. “Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections.” Contraception (2010) American College of Obstetricians and Gynecologists Committee on Gynecologic Practice: ACOG Committee Opinion No. 415: Depo medroxyprogesterone acetate and bone effects. Obstet Gynecol (2008)

11 Expected Bleeding Patterns after One Year

COMBINED ORAL CONTRACEPTIVES LEVONORGESTREL IUD Amenorrhea rate at 12 months: 53-72% Amenorrhea rate at 12 months: 50% Median number of bleeding or spotting days: 1. 5 days per 84-day reference period SUBDERMAL ETONORGESTREL IMPLANT TRANSDERMAL PATCH Mean number of bleeding or Amenorrhea rate at 3 months: 12% spotting days: 19 per 90-day Median number of bleeding or spotting reference days at 3 months: 14 days per 84-day DMPA reference period Amenorrhea rate at 3 months: 46-71% Percent of women with bleeding or spotting VAGINAL RING days per 90-day reference period Median number of bleeding or 1-7 days: 18% spotting days: 14 days per 90-day 8-10 days: 6% reference period >11 days: 12%

Kantartzis, K.L., Sucato, G.S. (2013) “Menstrual Suppression in the Adolescent”J Pediatr Adolesc Gynecol

Newsweek April 2016

$3.1"We billion menstruate dollars were spent and on femininethey see hygiene it products last year. Tampons and pads asare taxeddirty. in most states, while adult diapers,Attention Viagra, seeking. Rogaine and Sick.potato chips A are not. In India 1Rupi in 5 girlsKaur photo project dropburden. out of school after they startAs menstruating if this process due to lack is of lessadequate natural facilities to manage"To demystify the period and periods. make something innate than breathing. “MenstrualAs if it periods is not do anot bridge kill anyone, between but it is still an important issue“normal again” because it affects how girls view themselvesthis universeand they affect and confidence. the last. And confidenceAs if this is the processkey to everything.” is not love. 2015 wasLabour “The year. the Life. period Selfless went public” #HappytoBleed #TheHomelessPeriod #FreetheTamponsAnd strikingly#PeriodsarenotanInsult beautiful." – Rupi Kaur, "period"

The fight to end period shaming.

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