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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
Laboratory and imaging studies to evaluate
Menorrhagia
Management of acute Menorrhagia
Long term management of bleeding
disorders

Terminology

Abnormal uterine bleeding (AUB)

Menorrhagia (Hypermenorrhea)

Bleeding which is excessive or occurs outside of normal


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

Metrorrhagia

Irregular, frequent bleeding intervals

1.

Woolcock etal. Fert and Stertliny 2008; 6: 2269


Higham BrJ Obstet. Gynsecol 1990; 97: 734

2.

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 6 th
gynecologic year (ages 19-20)

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

Menstrual calendar paper or smart phone apps!


Symptoms of endocrinopathy:

Systems of bleeding disorders

Weight change, acne, facial or body hair


Heat/cold intolerance, breast development, galactorrhea

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.
2.
3.

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:
1.
2.

3.
4.

TSH
Platelet
function
screen
Prolactin
CBC

Management:
Menorrhagia without
Anemia
Most common etiology = anovulation
Order laboratory tests based on medical history
Management 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 contraception


Progestin only ocps
E + P Ocps

3.

NSAIDS

Common causes of menorrhagia


(without anemia) in adolescent
women include:
1.
2.
3.
4.

Anovulatory
cycles
Hypothalmic
disorders
Athletic
activities
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 + Anemia
Immediate: Control Bleeding

Noncyclic hormonal therapy


1.
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

2.

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
1.

2.

3.
4.
5.

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


1.
2.

3.

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:
1.

2.

3.
4.

Intravenous
conjugated
estrogen
Combined
hormonal
contraceptive
regimens
Both
Neither

4.

5.
6.

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

6.

Adjuvant Therapies
a.
b.
c.

Aminocaproic acid (antifibrinolytic)


Desmopressin (arginine vasopression analog)
Tranexamic acid (anti fibrinolytic)

Long Term Management of Adolescent


Women with Bleeding Disorders
1.

2.

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

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 Medications
a.
b.
c.

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:
1.

2.
3.

4.

Continuous
combined
estrogen and
progesterone oral
contraceptives
Levonorgestral
IUD
Depo
medroxyprogeste
rone acetate
All of the above

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