Management of Heavy Menses in Adolescent Women

Janice L. Bacon, M.D.

I have no financial relationships with any commercial interests related to the content of this activity today.

DISCLOSURE

Objectives

Discuss: Common causes of Menorrhagia in adolescent women

Laboratory and imaging studies to evaluate Menorrhagia

Management of acute Menorrhagia Long term management of bleeding

disorders

Terminology

Abnormal uterine bleeding (AUB) Bleeding which is excessive or occurs outside of normal

menses

Menorrhagia (Hypermenorrhea) Menstrual blood loss >80 ml/cycle Document #pads/tampons (or both) and saturation

Metrorrhagia Irregular, frequent bleeding intervals1. Woolcock etal. Fert and Stertliny – 2008; 6: 2269

2. Higham BrJ Obstet. Gynsecol 1990; 97: 734

Population Statistics

Population Statistics: 10-35% women report Menorrhagia

21-67% develop iron deficiency anemia

Overview of Etiology

Healthy Adolescents Anovulation Endocinopathy Bleeding disorder

Teens with Chronic disease Malignancy/Chemotherapy Medication effects Solid organ transplant Stem cell transplant

**Always exclude Pregnancy!

Adolescent Menses

Rarely drop hematocrit with first menses Frequently irregular up to 18-24 months 20% irregular up to 5 years postmenarchal Teens with early menarche may develop

ovulatory cycles earlier Normal cycle length established at 6th

gynecologic year (ages 19-20)

Flow: 2-7 d (excessive = > 8-10 d) Intervals: 21-34 d (ovulatory cycles) Polymenorrhea: regular bleeding intervals < 21 d Amount: 30-40 ml/menses (15-20 pads or tampons) By age 15, 90% females experience menarche

Menstruation in Girls and Adolescents. ACOG committee opinion, Nov. 2006.

Menstrual Parameters

Menorrhagia – Pertinent Facts

Menstrual calendar – paper or smart phone apps! Symptoms of endocrinopathy:

– Weight change, acne, facial or body hair– Heat/cold intolerance, breast development, galactorrhea

Systems of bleeding disorders– Petechiae, ecchymoses, epistaxis

Thorough history of personal and family medical disorders– Medications, gynecologic abnormalities– Sexual activity (obtain privately!)– Social history: Athletics, supplements, drugs, eating habits

Menorrhagia – Pertinent Exam Findings!

Total body survey![Take care to Provide teens some comfort and

modesty!]– Height and weight – measured– Calculate BMI– Pelvic exam or genital inspection and USG

Laboratory Tests – Menorrhagia

**Hgb/Hct is the most important discriminating test!

1. This may need to be checked before and after menses

2. Hgb <10 gms prompts further evaluation

3. Prior Hgb levels for comparison maybe helpful!

**Assess hemodynamic stability when acute bleeding present.

The most significant initial lab test for evaluation of menorrhagia in young women is:

1. TSH

2. Platelet function screen

3. Prolactin

4. CBC

Management:Menorrhagia without Anemia

Most common etiology = anovulationOrder laboratory tests based on medical historyManagement Strategies

Immediate: Menstrual Regulation (3-6 mos)1. Monthly Progesterone

Micronized P 400 mg qhs x 10 days

Medroxyprogesterone acetate 20 mg/d x 10 days

2. Cyclic hormonal contraceptionProgestin – only ocp’sE + P Ocp’s

3. NSAIDS

Common causes of menorrhagia (without anemia) in adolescent women include:

1. Anovulatory cycles

2. Hypothalmic disorders

3. Athletic activities

4. All of the above

Management Strategies

Long term: Menstrual Calendar:Consider other medical needs:

– Contraception– Acne/Hirsutism

Uncontrolled bleeding or recurrent episodes many prompt future evaluation

Medical Evaluation:

Menorrhagia + Anemia

Evaluation for Bleeding Disorders: CBC with differential PT, PTT Platelet function screen (collagen ADP) Von Willibrands factor antigen Ristocetin cofactor activity Factor VIIl activity

(Blood type 0=i VWf levels)

Evaluation for endocrinopathy: TSH, fT4 Prolactin Testosterone DHEAS 17-OHP

Evaluation of pelvic anatomy: USG, MRI Asses endometrial stripe/exclude ovarian cysts

Management Strategies: Menorrhagia + AnemiaImmediate: Control Bleeding

Noncyclic hormonal therapy1. Combined E + P methods

Pills Vaginal ring Patch

2. Combined E + P Pill taper: 4 pills / d x 4d 3 pills / d x 3d 2 pills / d x 2d One pill / d x 30 d Withdrawal bleed

(May combine routes of administration )3. Adjuvant Therapy

Antiemetics NSAIDS Tranexamic acid

Management Strategies: Menorrhagia + Anemia Long Term Management

1. Based on diagnosis– Correct endocrine disorder– Rx chronic medical conditions

(diabetes / liver dz / renal failure)

- Exclude bleeding disorders

2. Based on individual need– Contraception / Acne / Hirsutism

Evaluation of acute Menorrhagia/Hemorrhage

1. Asses current Hgb and hemodynamic status– Admit if Hgb < 7 gm– Admit if orthostatic or other medical conditions

2. Obtain:clotting studies complete metabolic profilepertinent endocrine studies

3. Draw labs for bleeding disorder if new event and transfusion pending

4. Assess pelvic anatomy (USG)5. Occasionally an exam under anesthesia and D&C may be

needed

Management of Acute Bleeding

1. E + P hormonal contraceptive tablets every 4 hrs. (usually 4-8 tabs)

2. IV conjugated estrogen (25 mg IV every 4 hours)– Add progestin after 2-3 doses– Antiemetic required!– Start E + P contraceptive regimen in 24 – 48

hours

3. Transfusion of Blood products Dr. Vore, et al. Obstet Gynecol (1982) 59; 285.

Options for Management of Acute Menorrhagia (Hemorrhage) in Young Women Include:

1. Intravenous conjugated estrogen

2. Combined hormonal contraceptive regimens

3. Both

4. Neither

4. If E contraindicated:– Norethindrone 5-10 mg every 4 hrs, then transition to QID dosing

with subsequent taper– Alternative progestin's

medroxyprogesterone acetate (40-80 mg / d) Depomedroxy progesterone 100 mg daily x one week, then

taper Megestrol acetate 80 mg bid GnRH analog

5. Dilatation and curettage – If bleeding uncontrolled after 24 – 36 hrs

6. Endometrial balloon or packingEndometrial ablation, uterine artery embolization or

hysterectomy are not appropriate for adolescent women

6. Adjuvant Therapiesa. Aminocaproic acid (antifibrinolytic)

b. Desmopressin (arginine vasopression analog)

c. Tranexamic acid (anti fibrinolytic)

Long Term Management of Adolescent Women with Bleeding Disorders

1. Combined E + P contraceptive regimens– Noncyclic– Monophasic 30-50 mg estrogen regimen may be most successful– Vaginal ring and patch also good choices

2. Progestin only regimens – P- only OCP– Etonogestrel Implant– Depomedroxyprogesterone acetate injections

• May control bleeding less perfectly due to endometrial atrophy

Fraser, et a. Aust. NZ Obstet Gynaecol 1991; 311: 66-70

3. Levonorgestral IUS Evidence of good success in patients with a variety of

bleeding disorders Insert after acute bleeding controlled

Ref: BJ Obstet Gynecol. June (1998) 105; p. 592

AMJ Obstet Gynecol (2005) 193: 1361

BJ of Obstet Gynaecol (1990) 97: 690

Contraception (2009) 79: 418

4. Adjunctive Medicationsa. Aminocaproic acid (5g) initially, then 1000 mg

every hour x 8 (or 4-5 doses)

b. Desmopression 0.3 mg/kg IV – repeat in 48 hrs.

c. Tranexamic acid 650 mg – 2 tabs TID

Long-term management of menses in women with bleeding disorders include:

1. Continuous combined estrogen and progesterone oral contraceptives

2. Levonorgestral IUD

3. Depo medroxyprogesterone acetate

4. All of the above