More Than Menorrhagia VIIA D. ANDERSON, APRN HEMATOLOGY NURSE PRACTITIONER JANE GEYER, APRN, WHNP-BC GYNECOLOGY NURSE PRACTITIONER Objectives Summarize menstrual physiology Define heavy menstrual bleeding (HMB) Explain common bleeding disorders associated with HMB Describe the evaluation process of HMB and Iron Deficiency Anemia (IDA) Introduce common pharmacologic agents used to control HMB and IDA Explain the TCH referral process for patients with HMB and IDA 13 yo obese female presents to PCP for annual visit History of migraines (with aura) well controlled with prn Imitrex History of epistaxis, but epistaxis occurring more frequently since starting softball Case Study: Last nosebleed 1 month ago while at the movies with her boyfriend Tiffany Menarche attained 6 months ago Menses occurs 1-2 times/month Menses 10 days in duration Temp 37C, HR 101, RR 18, BP 100/62 Pallor Fatigue Lab Normal Ranges Result WBC 4.5-13 6.49 Hemoglobin 12-16 gm/dl 7.5 gm/dl MCV 78-95 fl 69 fl Platelet 150-450 563 Lab Absolute Retic 0.042-0.065 0.026 Count UPT Negative Results PT 10.5-15.7 seconds 11 seconds PTT 25.2-33.2 seconds 38 seconds TSH 0.5-4.3 mIU/L 0.81 mIU/L Vwf antigen 56-176% 38% Vwf activity 50-150% 34% Factor 8 47-169% 35% Von Willebrand ratio 0.7-1.2 0.9 If you encounter abnormal labs you are not sure how to interpret………… Refer, Refer, Refer! We’re here to help! The Menstrual Phase 1: Follicular Phase Phase 2: Luteal Phase Cycle • Begins day 1 of the menstrual • Begins on the day of the LH cycle Surge • Ovarian follicle present typically The first day of menses represents the first day of a menstrual cycle. present on ovary approximately 26 hours following ovulation. The menstrual cycle is divided into 2 phases: • Low serum estradiol and • Endometrial lining thickens progesterone hormones trigger • The subsequent decrease in a negative feedback response estradiol/progesterone levels in which GnRH pulse following ovulation causes frequency is increased, which regression or resolution of causes an increase in FSH. follicle/corpus luteum. • The increase in FSH causes a • Regression of corpus lutem rise in estradiol production, and causes loss of endometrial a formation of a dominant blood supply and ultimately, GnRH: gonadotropin releasing hormone follicle. Ovulation occurs. sloughing of the uterine lining, or • Estradiol peaks mid cycle, then onset of menses. GnRH: gonadotropin releasing hormone mid cycle surge causes positive feedback loop activation, and FSH: follicle stimulating hormone a rise in LH levels. Normal Menstrual Cycles Average age of menarche in the US: currently 12 years (12.8 in NHC females, and 12.2 in AA females) More cycle variability in menstrual cycles within the first 5 – 7 years following menarche. By year 1 following menarche, up to 65% of females will have a regular menstrual cycle of at least 10 periods per year. For females that reach menarche at age 13 will likely achieve regular menses at a slower rate. Approximately 50% of this population will have regular menses within 4.5 years of menarche. Normal Menstrual Cycles in Adolescents Vs Adults Adolescents: Adults: Menstrual cycle length: 21-45 days Menstrual cycle length: 28-35 days Duration of menstrual bleeding: 2-7 Duration of menstrual bleeding: 4-6 days days Median blood loss: 30ml Median blood loss: 30 ml (approximately 3 – 6 pads per day) (approximately 3 – 6 pads per day) Abnormal Uterine Bleeding Amenorrhea or lack of menses Abnormal intervals of menses Excessive volume or duration of flow **Heavy menstrual bleeding only applies to patients with heavy menses with regular, ovulatory cycles** Pictorial blood loss assessment chart (PBAC) The PBAC generates a score based on number of pads/tampons changed, percentage of saturation, and passage of blood clots. A score of >= 100 has been associated with heavy menstrual bleeding (HMB). Causes of AUB in adolescents Most common cause of AUB in adolescents within 1-2 years of menarche is anovulatory bleeding. Up to 20-30% of patients with heavier than usual menstrual bleeding will be found to have an underlying bleeding disorder, such as von Willebrand disease. Other differential diagnoses: Pregnancy, polycystic ovarian syndrome (PCOS), thyroid disorders, hypothalamic dysfunction (due to obesity, low BMI, stress, excessive exercise) and/or sexually transmitted infections (STIs). Initial Gynecological Workup Other considerations may include CBC Iron Panel • Gonorrhea/Chlamydia TSH • Urine Pregnancy Test von Willebrand Panel (includes von Willebrand antigen, von • Pelvic Ultrasound Willebrand activity, factor VIII • Androgen levels levels, and aPTT) • Prolactin levels Fibrinogen • Estradiol/LH/FSH PT/INR Treatment options Hormonal treatments: Hemostatic treatments: Combined hormonal contraceptives: Tranexamic Acid pills, patch, vaginal ring Aminocaproic Acid Progestin only contraceptives: pills, Desmopressin (Stimate) injection, subdermal implant, intrauterine device Factor therapy Platelet transfusion Combined hormonal contraceptive pills Side effects: • Nausea when first initiated. Taking the Combined birth control pills (COCs) pills at night with food may help. contain two hormones, estrogen and • Irregular bleeding patterns when first progestin. initiated, which improve within 3 The combined pills are typically used for months of use. 21-24 days at a time, with a hormone • Mild headaches when first initiated. free interval of 4-7 days. This should improve within 3 months of Menstrual bleeding should occur during use. the hormone-free interval of the pill • COCs do not cause mood changes or pack. weight gain. COCs may be contraindicated in • Risk of a stroke or a blood clot! certain medical conditions, please refer Remember ACHES to CDC recommendations. Combined Hormonal Contraceptive Patch The patch contains two hormones, Side effects: estrogen and progestin. • Skin irritation. The patient should rotate The transdermal patch can be applied placement sites to help decrease topically to the buttock, abdomen, upper arm, or upper torso. irritation. • Irregular bleeding patterns when first The patch should be changed every 7 initiated, which improve within 3 days on the same day of each week for 3 consecutive weeks. months of use. • The patch does not cause mood The patch should then be removed for 7 changes or weight gain. days for a hormone-free interval. A new patch should be placed following • Stroke or blood clot risk! Remember the 7 days. ACHES Combined Hormonal Vaginal Ring The vaginal ring contains two Side effects: hormones; estrogen and progestin. • Irregular bleeding when first initiated. The vaginal ring is inserted intravaginal This should improve within 3 months of (with or without a tampon applicator). use. • The ring should not cause weight gain The ring stays inside the vagina for 21 or mood changes. days, and is then removed for 7 days for a hormone-free interval. • Risk of stroke or blood clot: Remember A new vaginal ring should be inserted ACHES! after 7 days. Progestin Only Contraceptive pill Referred to as the “mini-pill” contains only one Side effects: hormone called norethindrone. • Irregular bleeding - typically most The POP comes in a pack with 28 days of active common within first 3 months of use hormones and does not contain a “hormone free” pill. • Amenorrhea - considered normal with perfect use. This pill is less effective as contraception and is typically used in patients with contraindications to • The POP does not cause weight gain. estrogen containing contraceptives. • Not as effective as contraception. The POP should be taken daily at the same time. If the pill is taken >3 hours late from scheduled time, it is considered a missed dose. The patient should take the missed dose as soon as it is remembered, and continue with the rest of the pills as scheduled. Progestin only injection Contains one progestin hormone. Side effects: The shot is typically given every 11-13 • Weight gain weeks, but the interval between doses • Decreased bone mass density (BMD) may be adjusted based on patient • Irregular menstrual bleeding specific needs. Can be given Q 1 • Mood changes? month if needed for suppression. Can be given up to Q 15 weeks if needed for contraception. It can be given intramuscularly or subcutaneously. Progestin only subdermal implant Subdermal contraceptive implant: Side effects: Contains a progestin only hormone, etonorgestrel Side effects: Subdermal rod inserted in the arm. Lasts for up to 5 years for contraception but is currently FDA Irregular menstrual bleeding patterns (as approved for 3 years. highlighted above) Not considered first tier for menstrual suppression Does not effect BMD A study on bleeding patterns in Nexplanon users Weight gain in 12% of users. Mean weight revealed 22% of patients have amenorrhea, 34% had fewer than 3 spotting/bleeding episodes in gain was 3kg in 36 months. 90 days, and the remainder of patients had prolonged or more frequent menses.1 Approximately 50% likelihood of reduced menstrual bleeding Intrauterine devices (IUDs) The levonorgestrel IUD is currently FDA Side effects: approved for heavy menstrual bleeding. • Irregular bleeding The IUD is a t-shaped device inserted into the uterine cavity. • Cramping following insertion • Spotting It is typically placed in the office as an outpatient procedure. In special • Expulsion of the device circumstances, the IUD may be inserted in the operating room or a special procedure room, to allow for more advanced bleeding