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Dysfunctional Uterine Bleeding in the Adolescent

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Dysfunctional Uterine Bleeding in the Adolescent Jennifer E. Dietrich MD, MSc Division of Pediatric and Adolescent Gynecology Department of Obstetrics and Gynecology – PowerPoint PPT presentation

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Title: Dysfunctional Uterine Bleeding in the Adolescent


1
Dysfunctional Uterine Bleeding in the Adolescent
  • Jennifer E. Dietrich MD, MSc
  • Division of Pediatric and Adolescent Gynecology
  • Department of Obstetrics and Gynecology
  • Baylor College of Medicine

2
Disclosures
  • I the following financial relationships with a
    commercial interest
  • CSL Behring
  • Merck
  • Duramed
  • Bayer

3
Basic Terminology can be Confusing
  • Polymenorrhea
  • Oligomenorrhea
  • Amenorrhea
  • Metrorrhagia
  • Menometrorrhagia

4
Polymenorrhea
  • Frequent regular or irregular bleeding at lt21 day
    intervals

5
Oligomenorrhea
  • Infrequent irregular bleeding at gt35 day intervals

6
Irregular Menses
  • Bleeding at varying intervals gt21 days but lt45
    days

7
Metrorrhagia
  • Intermenstrual irregular bleeding between regular
    periods

8
Menorrhagia
  • Excessive amount and increased duration of
    uterine bleeding gt7 days, occurring regularly

9
Menometrorrhagia
  • Frequent irregular, excessive prolonged episodes
    of uterine bleeding gt7 days in duration

10
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

11
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
  • lt21 days between cycles? Needs evaluation!
  • gt35 days between cycles? Needs evaluation!
  • With each menstrual cycle, bleeding that lasts
    for more than 7 days? Needs evaluation!

12
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.
13
Menstruation Additional Practical Points
  • Educate Moms and Daughters about what is normal
    in the first year
  • 21-45 days (how to count)
  • lt/ 7 days of flow
  • 3-6 pads/day is typical
  • Variation in pad/tampon capacity
  • WRITE IT DOWN!

14
Menstrual calendar
15
The most common causes of DUB in an adolescent
  • Annovulation
  • Infections
  • Do not forget to check a pregnancy test!

16
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

17
Physical Exam
  • Assess stabilitycheck vitals
  • General- presence of noticeable factors (ie.,
    hirsute features)
  • Thyroid
  • Breast
  • Abdomen
  • Pelvic

18
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.
19
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.
20
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.
21
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.
22
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.
23
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.
24
Differential Diagnosis
  • Hematologic
  • Von Willebrands
  • 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.
25
In the U.S.
  • Over 2-3 million U.S. women have an underlying
    bleeding disorder.
  • gt300,000 hysterectomies/year occur for
    menorrhagia alone

James A. More than menorrhagia, a review of the
obstetric and gynecological manifestations of
bleeding disorders. Haemophilia. 2005 11295.
26
Bleeding Disorders
  • In the general population 1 of individuals
    worldwide are diagnosed with von Willebrands
    Disease.
  • Bleeding disorders are common in women with
    menorrhagia with prevalence ranging from 10-50
  • Von Willebrands 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 11295.
27
Give me the stats!
  • Average time to diagnosis for a woman with
    menorrhagia is 8 years!
  • Distribution 7030 (femalemale)
  • 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 11295.
28
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

29
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
Willebrands disease report menorrhagia at the
onset of menarche 50 of the time and 93 of the
time by the time they reach adulthood.
30
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!
31
What types of bleeding disorders are most common?
  • Von Willebrands Disease (Prevalence1)
  • 3 types
  • Type 1
  • Type 2many subtypes
  • Type 3
  • Platelet function defects

32
Bleeding symptoms in women with vWD
James A, Ragni MV, Picozzi V. Bleeding
disorders in post menopausal women (another)
public health crisis for hematology? Hematology
2006.
33
NHLBI Testing Recommendations 2008
  • Primary
  • CBC, PT, PTT, fibrinogen
  • VWF Ag, Ristocetin Cofactor, Factor VIII
  • Values lt30 are convincing
  • Values 30-50 may be VWD or simply low VWF
  • Secondary
  • Multimers, genetic testing
  • Specialized platelet testing, RIPA, ratios

34
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

35
Correlates of gt80ml blood loss
  • Bleeding heavier than one pad/hour
  • Low serum ferritin
  • Passing clots greater than 1 inch diameter
  • PBAC score gt100

NHLBI Guidelines 2008
36
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 73108-114.
37
The Acute Bleed
  • History and exam are critical!
  • Recommended work-up
  • CBC, TSH, von Willebrands 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

38
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

39
How do hormones work?
Negative feedback loop
OCPs, Contraceptive Ring, Contraceptive
patch, Injection
Estrogen and Progesterone
FSH and LH
Results Suppression of hormonal activity
40
Hormones Come in Many Shapes and Sizes
41
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)

42
Treatment of mild, moderate and severe episodes
with known negative pregnancy test
43
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 visitsrecheck blood
    work.

44
Managing the Chronic DUB patient
  • The bleeding may not be quite as heavy, or have
    lasted quite as longrest assured it has been
    just as much of a nuisiance to the patient.
  • MANY options for hormonal management.

45
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.
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