Maria C Monge MD Director of Adolescent Medicine Dell Childrens Medical Center UTSWAustin Pediatrics Residency Program Lone Star Circle of Care Disclosures I have no relevant financial disclosures ID: 703591
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Slide1
Abnormal Uterine Bleeding in Adolescents
Maria C. Monge, MD
Director of Adolescent Medicine
Dell Children’s Medical Center
UTSW-Austin Pediatrics Residency Program
Lone Star Circle of CareSlide2
Disclosures
I have no relevant financial disclosures.Slide3
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
.Slide4
Case – MadelineSlide5
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. Slide6
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 unremarkableSlide7
NORMAL MensesSlide8
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 20-80mLSlide9
Normal MensesSlide10
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 sheddingSlide11
Madeline
On arrival to office -- History
In the midst of her 3
rd
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 hoursSlide12
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 disorderSlide13
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 6
th
grade, has a boyfriend but no sex, no trauma, no foreign bodies in vaginaSlide14
Differential diagnosisSlide15
Differential for abnormal bleeding
Anovulatory
uterine bleeding
Endocrine disorders
Bleeding disorders
Pregnancy-related complicationsInfection
Hormonal contraception
Use of IUDs
Medications
Vaginal, cervical or uterine carcinoma, sarcoma, polyps
Cervical
hemangioma
Congenital uterine abnormalities
Vaginal lacerations, trauma
Endometriosis
Foreign bodySlide16
What is on our differential for Madeline?
Systematic approach
Consider pertinent history and physicalSlide17
What is on our differential for Madeline?
Systematic approach
Prolactinoma
Thyroid Disease
Cushings
, CAH
PCOS,
Anovluation
, Pregnancy, POI, Trauma, Infection, Polyp
Bleeding DisorderSlide18
Exam considerationsSlide19
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 bodiesSlide20
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
, bruisingSlide21
Any changes to the differential?
Anything move up or down the list?Slide22
Laboratory evaluationSlide23
Laboratory Evaluation
CBC with differential
B-
hcg
(sensitive urine or serum)
TSH, free T4Type and ScreenFSH, LH,
prolactin
, free/total T, DHEA-S
PT/PTT, von
Willebrand
panel
GC/CT testingSlide24
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)Slide25
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 biasSlide26
Role of imaging?
Consider if:
Unable to do pelvic exam
Prolonged bleeding despite treatment
Pelvic mass or uterine anomaly suspectedSlide27
Next steps?
Stop bleeding
Treat underlying condition (if applicable)Slide28
Key points for all patients
All patients should keep a menstrual calendar
Ensure iron stores are addressed, even if
H
gb
normal.
Patients typically need several months of oral iron to replete storesSlide29
Hormonal Treatment of bleedingSlide30
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 productSlide31
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 progestinSlide32
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)Slide33
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
C
an 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 reliabilitySlide34
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 indicatedSlide35
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-IUSSlide36
Indications for referralSlide37
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 identifiedSlide38
Take home pointsSlide39
Conclusions
Remember what is “normal”
Differential broad
History is important
Menstrual history as a “vital sign”
CBC to guide treatment
Different treatment options existSlide40
Thank you!
Contact
information:
Maria C. Monge, MD
Director of Adolescent Medicine
UTSW-Austin Pediatrics Residency Program
312-498-3470
mcmonge@hotmail.com