Download Abnormal Uterine Bleeding in Adolescents

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 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
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•
•
•
•
•
•
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, MD
Director of Adolescent Medicine
UTSW-Austin Pediatrics Residency Program
312-498-3470
[email protected]