Abnormal Uterine Bleeding in

Adolescents

Julie L. Strickland
Jeffrey W.Wall

Obstetrics and Gynecology Clinics

June 2003
 Introduction
• Abnormal Uterine bleeding is common in adolescent
years.
• Common cause of uterine bleeding is anovulation
due to lack of maturity of HPO axis
• Other pathologic condition: reproductive tract
anomaly,systemic illnesses,complication of
pregnancy, coagulation disorders.
• Knowledge of menstrual cycle is essential to
develop diagnostic protocols and adolescent
specific treatment.
 The menstrual cycle

• The menstrual cycle represents a complex

interrelationship of hormones and physiologic
events in the brain, ovary and uterus.
• The changes will prepare the body for
implantation or sloughing of the endometrium.
• The average cycle lasts 28 days, separated into 2
phase: follicular and luteal phase.
Follicular phase:
• Begins with sloughing of endometrium ,
culminates with ovulation (14 days)
• Marked by development of ovarian follicles and
endometrial growth.
• Predominat hormone is estrogen under influence
of GnRH, FSH, LH, inhibin
• Estrogen (Estradiol) increases until D13-14 and
lead to a LH surge and ovulation
Luteal phase:
• Begins with ovulation culminates with
mentruation or conception
• Marked with follicle transformation to corpus
luteum, produces progesterone
• The Progesterone level increases and reaches
steady state for 11 days.
• In absence of pregnancy, Corpus Luteum
involutes, progesterone decrease and leads to
menstruation
 Adolescents Menstruation
• Pubertal milestone: onset of menstruation
• Maturation of the HPO axis continues until 5
years of the onset
• Lemarchand-Beraud:
– Year 1: E,P, FSH, LH: below adult level
– Year 2: Estradiol increases to adult level
– Year 5: FSH, LH increase to adult level, P still low
• The cycle is often irregular initially, but
become more predictable later on
 Adolescents Menstruation
• In the first 3 year after menarche, the cycle
ranges from 21-45 days
• Mc Donough-Grant:
– In first 2 years: 55-82 % anovulatory
– By 4-5 years: only 20% anovulatory
• Anovulatory cycle the cause in 50-74%
inpatien due to severe bleeding
• Experince heavy bleeding, prolonged
menstruation due to anovulatory cycle
Differential Diagnosis
• Exclude the possibility of pregnancy
complication
– in US, >900.000 adolescence pregnancy and
majority is unplanned.
– Teens may be reluctant the possibility of
pregnancy
• The character, frequency and associated
presenting symptoms can suggest the
diagnosis
 Differential diagnosis
Pregnancy related Hypertiroidism
Ectopic pregnancy Infection
Threatened Abortion Trauma
Disordes of coagulation
Systemic disease
von Willebrand’s disease
Renal disease
Factor XI deficiency
Diabetes
Glassmans
Disorders of reprod. tract
Thrombocytopenia
Leiomyoma
Leukemia (fibrinogen deficiency)
Endometriosis
Endocrinopathies
Congenital anomalies
Androgen disorders
Servical polip
Policystic ovarian Sindrom
Congenital adrenal hyperplasia
Androgen secreting tumor
 Differential Diagnosis
• Heavy, prolonged, reccurent menstrual
periods may represent :
– underlying coagulation defect.
– Disorders of platelet dysfunction
• In the presence of severe bleeding, trauma
and genital injury (rape, sexual abuse,
retaining tampon, foreign object) must be
excluded
 Clinical Evaluation

• Many adolescents are anxious about

gynecologic evaluation.
• We need to be patience and orientation to
their special needs and concern
• Establish relaxed atmosphere, respect
privacy and autonomy.
• Confidentiality interviewed alone /
together
 Clinical Evaluation
• Obtain complete medical history, Growth pattern and
pubertal milestone, growth spurt and menarche.
• Record a detailed menstrual pattern.
• Ask a sexual history in non-threatening way .
• If the teen is not sexually active, it gives opportunity to
discuss sexuality issue and explaining about STD’s.
• Obtain general metabolic parameters (endurance, heat
and cold tolerance, sleep pattern). Body weight
history, rapid changes in body weight.
• Get the family history of bleeding.
 Clinical Evaluation

Physical examination:
• Vital sign, including height and weight
• Major body system, especially skin and neurologic
system (for endocrinology and systemic disease)
• Petechial hemorhage or echymosis
• Tanner staging of breast and pubic hair (hormonal
marker)
• Excessive androgen stimulation (acne, hair growth)
 Clinical Evaluation
Gynecology examination:
• Should be tailored to age and clinical situation
• Adequate time for explanation, patience, gentleness
during examination
• Speculum may not be necessary in patien who has not
initiated sexual intercourse, except heavy bleeding, pain
an gynec symptom
• If needed speculum, use a narrow, stright blade
speculum
• If suspected sexual activity, take culture
• To assess pelvic mass or pelvic anatomy abormality
perform single digit or recto abdominal exam.
 Laboratory Assessment
• Pregnancy test is initial test before beginning any
assessment
• Initial evaluation
Complete blood count, differential
Platelet count
Fibrinogen
Prothrombin time
Partial tromboplastin time
Bleeding time
• If bleeding is severe/prolonged/associated w
menars/initial screen in abnormal
von Willebrand factor antigen
Factor VIII activity
Factor XI antigen
Platelet aggregation studies
 Laboratory Assessment
• If there is systemic or metabolic disease:
do thyroid, adrenal, other systemic disease
test.
• If there is hyperandrogenism: check T,
DHEAS,17-OH progesteron, Gonadotropin,
Fasting insulin and glucose level
• If atipical bleeding :transabdominal USG
• If prolonged bleeding, severe
hyperandrogenism, obesity, carcinoma:
endometrial sampling
• If abnormal anatomy: transperineal USG,
MRI
 Treatment
• Goal:
– To identify the source of bleeding and direct
th/
– To stop abnormal bleeding
– To help adolescent have more predictable,
manageable menstrual cycle
• If there is profuse bleeding, hypovolemic, Hb<9
g/dl resuscitation: volume expansion/ blood
product
• The most effective: hormonal therapy (93%
respond)
 Treatment
• Hormonal therapy for severe, acute bleeding:
– Conj. Equine estrogen 25mg/4 h, iv
– Continue with CEE 2,5 mg (20-25 d)
– MPA 10 mg (for the last 7-10 d)
– Or followed by OC
• Antifibrinolytic therapy
• If bleeding prolonged: CEE 2,5 mg (21-25d)
followed MPA 10 mg (last 7 d) or OC
accelerated dose (2x1 for 1 week, followed
1x1 for 3 weeks)
 Treatment
• For only mild symptom of menstrual
irregularity or prolonged menses:
reassurance and education is sufficient
therapy.
• For heavy, prolonged menses: add NSAID ,
antifibrinolytic
• Limited use in treatment of abnormal
bleeding:
– DMPA, LNG impregnated IUD
– GnRH agonist
– Surgical management: D&C/ Hysteroscopy
 Prognosis
• Irregular, unpredictable, heavy bleeding in
adolescent occurs as result of lack of
maturation of HPO axis.
• Over the first 3-5 postmenarchal years, most
will develop regular, cyclic menses.
• If normal menses has not develop in 4 years,
the chance for normal menstrual function is
low.
• Many of these women : decreased reproductive
potential, endometrial Ca, subsequent
gynecologic surgery surgery.
 Summary
• Abnormal and irregular bleeding are extremely
common in the adolescent period and can be
looked as apart of normal reproductive
development.
• It is essenstial to have a firm grasp on normal,
physiologic development of the menstrual
cycle.
• It is important to recognize the distinc needs,
goals, and development stages of adolescent
patient.
• No single therapy or approach is universal in
the diagnosis and treatment, but must be
tailored to individuals and situation.