Dysfunctional Uterine Bleeding in the Adolescent
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Transcript of Dysfunctional Uterine Bleeding in the Adolescent
Dysfunctional Uterine Bleeding in the Adolescent
Jennifer E. Dietrich MD, MScDivision of Pediatric and Adolescent Gynecology
Department of Obstetrics and Gynecology
Baylor College of Medicine
Disclosures
• I the following financial relationships with a commercial interest:
• CSL Behring
• Merck
• Duramed
• Bayer
Basic Terminology can be Confusing
• Polymenorrhea
• Oligomenorrhea
• Amenorrhea
• Metrorrhagia
• Menometrorrhagia
Polymenorrhea
• Frequent regular or irregular bleeding at <21 day intervals
Oligomenorrhea
• Infrequent irregular bleeding at >35 day intervals
Irregular Menses
• Bleeding at varying intervals >21 days but <45 days
Metrorrhagia
• Intermenstrual irregular bleeding between regular periods
Menorrhagia
• Excessive amount and increased duration of uterine bleeding >7 days, occurring regularly
Menometrorrhagia
• Frequent irregular, excessive prolonged episodes of uterine bleeding >7 days in duration
Pubertal Effects
• Menses should occur ~2 years after thelarche
• Expect menses to gradually become more regular
• Most adolescents should have regular cycles within 2-3 years of menarche
What is a normal menstrual cycle for an adolescent just beginning menarche?
• Average age of first menses is 12.5 years of age
• Menstrual cycles can be irregular for up to three years after onset of the first cycle
• Bleeding should occur between every 21-35 days– <21 days between cycles Needs evaluation!– >35 days between cycles Needs evaluation!– With each menstrual cycle, bleeding that lasts for more
than 7 days Needs evaluation!
General Features of Menses by Gynecologic Year
• First Gynecologic Year– 5 % = 23 days– 95 % = 90 days
• Fourth Gynecologic Year– 95 % = 50 days
• Seventh Gynecologic Year– 5 % = 27 days– 95 % = 38 days
• Cycle length more VARIABLE for teens than women 20-40 years of age
Treloar AE et al. Variations in the human menstrual cycle through reproductive life. Int J Fertil, 1967. 12: 77-126. 275,947 cycles in 2702 women over 27 years.
Menstruation: Additional Practical Points
• Educate Moms and Daughters about what is normal in the first year:
– 21-45 days (how to count)– </= 7 days of flow– 3-6 pads/day is typical
• Variation in pad/tampon capacity – WRITE IT DOWN!
Menstrual calendar
The most common causes of DUB in an adolescent
• Annovulation
• Infections
• Do not forget to check a pregnancy test!
Importance of History
• Timing• Menstrual history• Pad/tampon count and size• Presence of vaginal discharge• Presence of abdominal pain• Past medical history• Medication exposures• Personal and/or family history of easy bruising,
gingival bleeding or epistaxis
Physical Exam
• Assess stability—check vitals
• General- presence of noticeable factors (ie., hirsute features)
• Thyroid
• Breast
• Abdomen
• Pelvic
Differential Diagnosis
• Annovulation (most common)– Due to immaturity of the hypothalamus– Hypothalamic dysfunction– Polycystic ovarian syndrome
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
Differential Diagnosis
• Pregnancy-related– Miscarriage– Ectopic pregnancy– Retained products after elective termination
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
Differential Diagnosis
• Chronic Diseases– Renal– Liver
– Thyroid– Diabetes
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
Differential Diagnosis
• Infections– Chlamydia– PID
– Shigella
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
Differential Diagnosis
• Neoplasms– Vaginal/cervical tumors– Polyps– Hemangiomas– Leiomyomas– Granulosa cell tumor
– Sertoli-Leydig cell tumor
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
Differential Diagnosis
• Other– Endocrine Disorders (thyroid is most common)– Anorexia Nervosa– Medications
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
Differential Diagnosis
• Hematologic– Von Willebrand’s– Platelet function defects– Idiopathic thrombocytopenic purpura– Other rare bleeding disorders
Strickland J, Gibson EJ, Levine SB. ”Dysfunctional uterine bleeding in adolescents,” J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
In the U.S.
• Over 2-3 million U.S. women have an underlying bleeding disorder.
• >300,000 hysterectomies/year occur for menorrhagia alone
James A. More than menorrhagia, a review of the obstetric and gynecological manifestations of bleeding disorders. Haemophilia. 2005; 11:295.
Bleeding Disorders
• In the general population 1% of individuals worldwide are diagnosed with von Willebrand’s Disease.
• Bleeding disorders are common in women with menorrhagia with prevalence ranging from 10-50%
• Von Willebrand’s is the most common of all bleeding disorders with a prevalence of 5-15% among those with bleeding conditions.
James A. More than menorrhagia, a review of the obstetric and gynecological manifestations of bleeding disorders. Haemophilia. 2005; 11:295.
Give me the stats!
• Average time to diagnosis for a woman with menorrhagia is 8 years!
• Distribution 70:30 (female:male)
• Overall prevalence higher in Northern European countries (18%)
• Prevalence of severe vWD highest in Sweden (1/200,000)
James A. More than menorrhagia, a review of the obstetric and gynecological manifestations of bleeding disorders. Haemophilia. 2005; 11:295.
American College of Obstetricians and Gynecologists (ACOG) Recommendations
• The first adolescent female health care visit should occur between the ages of 13 and 15
• Adolescents presenting with menorrhagia should be screened for bleeding disorders
How to AVOID missing a bleeding disorder
Of patients with a history of menorrhagia, 20% will have an underlying bleeding disorder.
Patients with a diagnosis of von Willebrand’s disease report menorrhagia at the onset of menarche ~50% of the time and 93% of the time by the time they reach adulthood.
Key elements from history
• Easy bruising
• Epistaxis
• Frequent gum bleeds
• Family history of menometrorrhagia, post partum hemorrhage, easy bruising, epistaxis, frequent gum bleeds, menorrhagia
Family history and menorrhagia probably most important!
What types of bleeding disorders are most common?
• Von Willebrand’s Disease (Prevalence=1%)– 3 types
• Type 1• Type 2—many subtypes• Type 3
• Platelet function defects
Bleeding symptoms in women with vWD
Symptom Number Reporting
Mean Age Onset
%Reporting %Transfused
Bruising 36 7 48 0
Nosebleeds 33 7 44 0
Bleeding after injury
25 11 33 11
Dental bleeding 38 16 51 36
Menorrhagia 63 13 84 18
Postoperative bleeding 36 17 48 12
Postpartum Hemorrhage 24 24 32 25
James A, Ragni MV, Picozzi V. “Bleeding disorders in post menopausal women (another) public health crisis for hematology?” Hematology 2006.
NHLBI Testing Recommendations 2008
• Primary– CBC, PT, PTT, fibrinogen– VWF Ag, Ristocetin Cofactor, Factor VIII
• Values <30 are convincing• Values 30-50 may be VWD or simply “low VWF”
• Secondary– Multimers, genetic testing– Specialized platelet testing, RIPA, ratios
The difficulty…
• Spectrum of disorders– Autosomal Dominant, Autosomal Recessive– Variable penetrance– Acquired forms
• No one test is “the best”• Repeating tests may be necessary
– Stress– Exercise– Pregnancy– Hormone use– Inflammatory states
Correlates of >80ml blood loss…
• Bleeding heavier than one pad/hour
• Low serum ferritin
• Passing clots greater than 1 inch diameter
• PBAC score >100
NHLBI Guidelines 2008
Morbidity
• Loss of time from work
• Psychological effects
• Loss of time from school
• Peer interactions
• Lifestyle modification
• Focussing ONLY on the bleeding condition
Barr RD, et. Al. “Health status and health-related quality of life associated with von Willebrand disease.” Amer J of Hematol. 2003; 73:108-114.
The Acute Bleed
• History and exam are critical!
• Recommended work-up– CBC, TSH, von Willebrand’s panel (vWD Ag,
Ristocetin cofactor, Factor VIII), Type and screen, PT, PTT, INR, fibrinogen, PFA 100
– Draw labs BEFORE administering hormones
• Imaging– Ultrasound– MRI in some cases
The Acute Bleed and Treatment
• Starting Hormones– IV Estrogen: recommended for the acute bleeding
episode in which patient is unable to tolerate po intake. May be given 25mg IV q6 hours until vaginal bleeding stops.
– Combination oral contraceptives• A 50 mcg pill with ethinyl estradiol has the SAME
bioavailability as conjugated equine estrogens administered IV.
• Pills should be administered every 6 hours until vaginal bleeding stops
• Tapers are useful-a variety of protocols exist
How do hormones work?
FSH and LH
Estrogen and Progesterone
OCPs, Contraceptive Ring, Contraceptive patch,
Injection
ResultsSuppression of hormonal
activity
Negative feedback loop
Hormones Come in Many Shapes and Sizes
Differences in Progestins
• Some are more androgenic than others
• Low, Medium and High dose Progestins
• Less breakthrough bleeding reported with levonorgestrel, norgestimate and desogestrel (all are MORE androgenic)
Treatment of mild, moderate and severe episodes with known negative pregnancy test
Amount of Bleeding Hb Management/Treatment
Mild>11
Reassurance, education. Offer iron and low dose OCP. Reevaluate 3 months
Moderate9-11
Education. Rule out STD and coagulopathy. Offer iron and low dose OCP taper. Reevaluate 2 months.
Severe7-9
Rule out coagulopathy. Offer iron and high dose OCP taper. Reevaluate in 4 weeks.
Hypovolemic Shock
<5-6
Stabilize, rule out coagulopathy. Offer transfusion. Admit for high dose hormones until VB stops (IV or po route). D&C or balloon tamponade in extreme cases.
Other tips for the acute bleed…
• May need to premedicate some patients with Phenergan or Odansetron during high dose hormone administration
• If labs return normal, but you remain clinically suspicious during follow up visits—recheck blood work.
Managing the Chronic DUB patient
• The bleeding may not be quite as heavy, or have lasted quite as long—rest assured it has been just as much of a nuisiance to the patient.
• MANY options for hormonal management.
Summary
• Dysfunctional uterine bleeding (DUB) is multifaceted in the adolescent patient
• The most common condition resulting in DUB for the adolescent is annovulation
• Bleeding is often easily controlled with hormonal manipulation
• Adolescents have a number of options these days to fit their needs
• Good evidence for guiding management in women with diagnosed bleeding disorders thus far, but more research is needed.