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Management of Heavy Menses in Adolescent Women. Janice L. Bacon, M.D. DISCLOSURE. I have no financial relationships with any commercial interests related to the content of this activity today. Objectives. Discuss: Common causes of Menorrhagia in adolescent women

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Presentation Transcript
disclosure

DISCLOSURE

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

objectives
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
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 intervals
    • Woolcock etal. Fert and Stertliny – 2008; 6: 2269
    • Higham BrJ Obstet. Gynsecol 1990; 97: 734
population statistics
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

Overview of Etiology

**Always exclude Pregnancy!

adolescent menses
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)
menstrual parameters
Menstrual Parameters
  • 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.

menorrhagia pertinent facts
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
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
Laboratory Tests – Menorrhagia

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

  • This may need to be checked before and after menses
  • Hgb <10 gms prompts further evaluation
  • 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
The most significant initial lab test for evaluation of menorrhagia in young women is:
  • TSH
  • Platelet function screen
  • Prolactin
  • CBC
management menorrhagia without anemia
Management:Menorrhagia without Anemia

Most common etiology = anovulation

Order laboratory tests based on medical history

Management Strategies

Immediate: Menstrual Regulation (3-6 mos)

Monthly Progesterone

Micronized P 400 mg qhs x 10 days

Medroxyprogesterone acetate 20 mg/d x 10 days

Cyclic hormonal contraception

Progestin – only ocp’s

E + P Ocp’s

NSAIDS

common causes of menorrhagia without anemia in adolescent women include
Common causes of menorrhagia (without anemia) in adolescent women include:
  • Anovulatory cycles
  • Hypothalmic disorders
  • Athletic activities
  • All of the above
management strategies
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

Medical Evaluation:
management strategies menorrhagia anemia immediate control bleeding
Management Strategies: Menorrhagia + AnemiaImmediate: Control Bleeding

Noncyclic hormonal therapy

  • Combined E + P methods
    • Pills
    • Vaginal ring
    • Patch
  • 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 )

  • Adjuvant Therapy
    • Antiemetics
    • NSAIDS
    • Tranexamic acid
management strategies menorrhagia anemia long term management
Management Strategies: Menorrhagia + AnemiaLong Term Management
  • Based on diagnosis
    • Correct endocrine disorder
    • Rx chronic medical conditions

(diabetes / liver dz / renal failure)

- Exclude bleeding disorders

  • Based on individual need
    • Contraception / Acne / Hirsutism
evaluation of acute menorrhagia hemorrhage
Evaluation of acute Menorrhagia/Hemorrhage
  • Asses current Hgb and hemodynamic status
    • Admit if Hgb < 7 gm
    • Admit if orthostatic or other medical conditions
  • Obtain:

clotting studies

complete metabolic profile

pertinent endocrine studies

  • Draw labs for bleeding disorder if new event and transfusion pending
  • Assess pelvic anatomy (USG)
  • Occasionally an exam under anesthesia and D&C may be needed
management of acute bleeding
Management of Acute Bleeding
  • E + P hormonal contraceptive tablets every 4 hrs. (usually 4-8 tabs)
  • 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
  • Transfusion of Blood products

Dr. Vore, et al. Obstet Gynecol (1982) 59; 285.

options for management of acute menorrhagia hemorrhage in young women include
Options for Management of Acute Menorrhagia (Hemorrhage) in Young Women Include:
  • Intravenous conjugated estrogen
  • Combined hormonal contraceptive regimens
  • Both
  • Neither
slide22
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
  • Dilatation and curettage
    • If bleeding uncontrolled after 24 – 36 hrs
  • Endometrial balloon or packing

Endometrial ablation, uterine artery embolization or hysterectomy are not appropriate for adolescent women

slide23
Adjuvant Therapies
    • Aminocaproic acid (antifibrinolytic)
    • Desmopressin (arginine vasopression analog)
    • Tranexamic acid (anti fibrinolytic)
long term management of adolescent women with bleeding disorders
Long Term Management of Adolescent Women with Bleeding Disorders
  • Combined E + P contraceptive regimens
    • Noncyclic
    • Monophasic 30-50 mg estrogen regimen may be most successful
    • Vaginal ring and patch also good choices
  • 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

slide25
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

slide26
Adjunctive Medications
    • Aminocaproic acid (5g) initially, then 1000 mg every hour x 8 (or 4-5 doses)
    • Desmopression 0.3 mg/kg IV – repeat in 48 hrs.
    • Tranexamic acid 650 mg – 2 tabs TID
long term management of menses in women with bleeding disorders include
Long-term management of menses in women with bleeding disorders include:
  • Continuous combined estrogen and progesterone oral contraceptives
  • Levonorgestral IUD
  • Depo medroxyprogesterone acetate
  • All of the above