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 Program312-498-3470mcmonge@hotmail.com