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1/29/16 Abnormal Uterine Bleeding
Oluyemisi Adeyemi-Fowode
Texas Children’s Hospital
Objectives
•  Outline the normal progression and timing of pubertal development
•  Review characteristics of normal and abnormal menses in
adolescent girls
•  Review probable causes and workup of abnormal uterine bleeding in
adolescent girls
•  Discuss management of abnormal uterine bleeding associated with
ovulatory dysfunction
1 1/29/16 Puberty
Breast bud
Mean
10.5
Onset pubic hair
Stages of Puberty
• 
• 
• 
• 
11.0
Peak height velocity
11.4
Menarche
12.8
Adult breast
Therlache (Breast development)
Pubarche (Pubic hair)
Growth Spurt (Peak height velocity)
Menarche (First menstrual period)
14.6
Adult pubic hair
13.7
8
10
12
14
16
18
Age in Years
Menarche
•  Age has remained relatively stable
–  Menarche: 12 years
–  2-3 years after thelarche
•  Typically at Tanner stage IV
–  Rare before Tanner stage III
•  Evaluation warranted
–  Lack of breast development: age 13
–  Primary amenorrhea: age 15
ACOG: Menstruation in girls and
adolescents: Using the menstrual sign
as a vital sign. Obstet Gynecol. 2015
Dec;126(6):e143-6.
2 1/29/16 Normal Menstrual Cycles in Adolescent Girls
Menarche (median age)
12.43
Mean cycle interval
32.2 days in first gynecologic year
Menstrual cycle interval
Typically 21-45 days
Menstrual flow length
7 days or less
Menstrual product use
Three to six pads or tampons per day
ACOG: Menstruation in girls and
adolescents: Using the menstrual sign
as a vital sign. Obstet Gynecol. 2015
Dec;126(6):e143-6.
Abnormal Uterine Bleeding
•  Once menarche is reached, uncommon to remain
amenorrheic for > 90 days
•  Mean blood loss per period: 30 ml
•  > 80 ml associated with anemia
Discontinuation of the term Dysfunctional Uterine Bleeding (DUB) is recommended
Limited clinical use!!!!! 3 1/29/16 Abnormal Uterine Bleeding
•  Flow requiring changes of menstrual products Q1-2 hrs
•  Flow lasting > 7 days at a time
Ask the patient to chart her menses
Technology
•  iOS & Android
–  Period Tracker
–  My Cycles
–  MonthPal
–  Pink Pad
4 1/29/16 PALM-COEIN Classification System
Abnormal Uterine Bleeding
•  Heavy menstrual bleeding (AUB/HMB)
•  Intermenstrual bleeding (AUB/IMB)
PALM–structural causes
COEIN–nonstructural causes
Polyp (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Coagulopathy (AUB-C)
Ovulatory dysfunction (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not yet classified (AUB-N)
•  Submucosal leiomyoma (AUB-LSM)
•  Other leiomyoma (AUB-LO)
Malignancy and hyperplasia (AUB-M)
Working group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3-13
Probable Causes of AUB by Age Group
Adolescent
(13-19 years)
Cause
20-35
years
35-45
years
Peri/postmenopausal
Anovulatory bleeding
in the adolescent
Bleeding disorder
(known or unknown)
Chronic menorrhagia with
acute deterioration
Local pathology eg, fibroid with
necrosis or endometrial polyp
Adding of a new systemic
disease eg, leukemia
Anticoagulant therapy
Postoperative complication
Hypothyroidism
Perimenopausal anovulation
AH James, et al. European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 124-134.
5 1/29/16 Causes of Anovulation
Physiologic
Pathologic
• 
• 
• 
• 
•  Hyperandrogenic anovulation (eg, PCOS, congenital adrenal
hyerplasia, or androgen-producing tumors)
•  Hypothalamic dysfunction (eg, secondary to anorexia nervosa)
•  Hyperprolactinemia
•  Thyroid disease
•  Primary pituitary disease
•  Premature ovarian failure
•  Iatrogenic (eg, secondary to radiation or chemotherapy)
Adolescence
Perimenopause
Lactation
Pregnancy
Irregular Bleeding
•  STIs
•  Malignancy
•  Uterine Lesions
•  Trauma
•  Medications
Management of Abnormal Uterine Bleeding
Associated With Ovulatory Dysfunction. Obstet
Gynecol. 2013 Jul;122(1):176-85.
Irregular Menses Panel
•  UPT
•  Testosterone panel
•  FSH/LH/Estradiol
•  DHEA-S
•  TSH
•  17-OHP
•  Prolactin
•  Pelvic US
6 1/29/16 Excessive Uterine Bleeding
•  Anovulation
•  Von Willebrand’s Disease
•  Liver failure
•  Malignancy
Excessive Bleeding
•  Anticoagulation
•  Trauma
•  Rare hematological conditions
–  Factor deficiencies
–  ITP
–  Aplastic anemia
ACOG: Menstruation in girls and
adolescents: Using the menstrual sign
as a vital sign. Obstet Gynecol. 2015
Dec;126(6):e143-6.
Heavy Menses Panel
•  UPT
•  PT/INR/PTT
•  CBC
•  Fibrinogen
•  TSH
•  Von Willebrand panel
7 1/29/16 AUB-O
•  Treatment goals
–  Halt abnormal bleeding
–  Prevent recurrence
–  Improve QOL
–  Avert morbidity
–  Simultaneously provide contraception
•  AUB-O is an endocrine abnormality
•  Exogenous steroids is an important component
Treatment for AUB-O
•  Combined Hormonal therapy
•  Progestin therapy
Combined Hormonal Therapy
Progestin Therapy
Combined Oral Contraceptives
Progestin only Pills
Transdermal patches
Depot medroxyprogesterone acetate
Vaginal ring
Etonorgestrel Implant
Intrauterine Device
8 1/29/16 Medical Conditions to Avoid Use of Estrogen
•  Uncontrolled hypertension
•  Severe liver disease
•  Severe cardiac
valve disease
•  Personal history of VTE
•  Rheumatic disease associated
with antiphosphopholipid
antibodies
•  Breastfeeding
•  Strong family history of VTE
•  Major surgery requiring long-term
immobilization
•  Migraines with aura
U.S. Medical Eligibility Criteria for Contraceptive Use
Oral Contraceptive Pills
Typical failure
rate: 9%
Kost K et al. Estimates of
contraceptive failure from the 2002
National Survey of Family Growth.
Contraception (2008) 77 p. 10-21.
9 1/29/16 Contraceptive Patch: Ortho Evra®
•  A treatment cycle consists of the application
of 3 patches for 7 days each, consecutively,
with a 7 day patch-free phase
•  Decreased efficacy at higher
BMI i.e. >198 lbs (90 kg)
Typical failure
rate: 8%
Kost K et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth.
Contraception (2008) 77 p. 10-21.
Depot Medroxyprogesterone Acetate
•  Depo Provera® 150 mg injected IM or 104 mg
SQ q 12 weeks
•  Most common side effects are:
–  Irregular bleeding
–  Weight gain
–  Decreased bone density
Typical failure
rate: 7%
Kost K et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth.
Contraception (2008) 77 p. 10-21.
10 1/29/16 Long-Acting Reversible Contraception
•  Contraceptive implants
–  Nexplanon®
•  Intrauterine devices
–  Paragard®
–  Mirena®
–  Skyla®
Typical failure
rate: <1%
•  Preferred method per AAP, ACOG
•  Most common side effect is irregular bleeding
Kost K et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth.
Contraception (2008) 77 p. 10-21.
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