Management of Heavy Menses in Adolescent Women Janice L. Bacon, M.D.
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Transcript of Management of Heavy Menses in Adolescent Women Janice L. Bacon, M.D.
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Management of Heavy Menses in Adolescent Women
Janice L. Bacon, M.D.
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I have no financial relationships with any commercial interests related to the content of this activity today.
DISCLOSURE
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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
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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 intervals1. Woolcock etal. Fert and Stertliny – 2008; 6: 2269
2. Higham BrJ Obstet. Gynsecol 1990; 97: 734
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Population Statistics
Population Statistics: 10-35% women report Menorrhagia
21-67% develop iron deficiency anemia
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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!
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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)
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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.
Menstrual Parameters
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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
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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
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Laboratory Tests – Menorrhagia
**Hgb/Hct is the most important discriminating test!
1. This may need to be checked before and after menses
2. Hgb <10 gms prompts further evaluation
3. Prior Hgb levels for comparison maybe helpful!
**Assess hemodynamic stability when acute bleeding present.
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The most significant initial lab test for evaluation of menorrhagia in young women is:
1. TSH
2. Platelet function screen
3. Prolactin
4. CBC
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Management:Menorrhagia without Anemia
Most common etiology = anovulationOrder laboratory tests based on medical historyManagement 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 contraceptionProgestin – only ocp’sE + P Ocp’s
3. NSAIDS
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Common causes of menorrhagia (without anemia) in adolescent women include:
1. Anovulatory cycles
2. Hypothalmic disorders
3. Athletic activities
4. All of the above
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Management Strategies
Long term: Menstrual Calendar:Consider other medical needs:
– Contraception– Acne/Hirsutism
Uncontrolled bleeding or recurrent episodes many prompt future evaluation
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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
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Management Strategies: Menorrhagia + AnemiaImmediate: Control Bleeding
Noncyclic hormonal therapy1. 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
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Management Strategies: Menorrhagia + Anemia Long Term Management
1. Based on diagnosis– Correct endocrine disorder– Rx chronic medical conditions
(diabetes / liver dz / renal failure)
- Exclude bleeding disorders
2. Based on individual need– Contraception / Acne / Hirsutism
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Evaluation of acute Menorrhagia/Hemorrhage
1. Asses current Hgb and hemodynamic status– Admit if Hgb < 7 gm– Admit if orthostatic or other medical conditions
2. Obtain:clotting studies complete metabolic profilepertinent endocrine studies
3. Draw labs for bleeding disorder if new event and transfusion pending
4. Assess pelvic anatomy (USG)5. Occasionally an exam under anesthesia and D&C may be
needed
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Management of Acute Bleeding
1. E + P hormonal contraceptive tablets every 4 hrs. (usually 4-8 tabs)
2. 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
3. Transfusion of Blood products Dr. Vore, et al. Obstet Gynecol (1982) 59; 285.
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Options for Management of Acute Menorrhagia (Hemorrhage) in Young Women Include:
1. Intravenous conjugated estrogen
2. Combined hormonal contraceptive regimens
3. Both
4. Neither
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4. 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
5. Dilatation and curettage – If bleeding uncontrolled after 24 – 36 hrs
6. Endometrial balloon or packingEndometrial ablation, uterine artery embolization or
hysterectomy are not appropriate for adolescent women
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6. Adjuvant Therapiesa. Aminocaproic acid (antifibrinolytic)
b. Desmopressin (arginine vasopression analog)
c. Tranexamic acid (anti fibrinolytic)
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Long Term Management of Adolescent Women with Bleeding Disorders
1. Combined E + P contraceptive regimens– Noncyclic– Monophasic 30-50 mg estrogen regimen may be most successful– Vaginal ring and patch also good choices
2. 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
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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
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4. Adjunctive Medicationsa. Aminocaproic acid (5g) initially, then 1000 mg
every hour x 8 (or 4-5 doses)
b. Desmopression 0.3 mg/kg IV – repeat in 48 hrs.
c. Tranexamic acid 650 mg – 2 tabs TID
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Long-term management of menses in women with bleeding disorders include:
1. Continuous combined estrogen and progesterone oral contraceptives
2. Levonorgestral IUD
3. Depo medroxyprogesterone acetate
4. All of the above