The etiology and optimal management of heavy menstruation in adolescents is often a sensitive issue for the concerned parents as well as the family physicians. Menstrual irregularities resulting in abnormal uterine bleeding are not uncommon in adolescents. Although heavy menstrual bleeding in adolescents is most commonly due to an ovulation, its association with bleeding disorders and the need of multidisciplinary approach in selected cases needs to be highlighted. Although several guidelines have been published for management of menorrhagia in adults, their applicability in this younger age group is not clear. To institute appropriate care in these patients, recognition of the cause and prompt treatment is essential.
Young girls and their mothers are often unsure about what represents normal menstrual patterns. The clinicians also need to be clear regarding terminology and definition of amount and duration of flow as well as the length of normal menstrual cycle during adolescence to be able to educate their anxious clients.1 There is considerable confusion worldwide in the use of terminologies and definitions around the symptom of abnormal uterine bleeding. A simple terminology has been recommended2. Good history taking to assess the amount of flow is a key to diagnosing the etiology. Menstrual blood flow requiring change of pads every 1-2 hours is considered heavy especially when associated with duration greater than 7 days.
In adolescents up to 95% of abnormal uterine bleeding is dysfunctional uterine bleeding most often anovulatory3.Although anovulatory cycles can occur in women at any age, it is most prevalent at extremes of reproductive age including the peri-menarche. Other causes of abnormal uterine bleeding must be excluded in a systematic manner. In local hospital based studies of pubertal menorrhagia, 90-92% had dysfunctional uterine bleeding while 8% had coagulation disorder.4,5 Other pathologies like infections, trauma, benign or malignant growths of genital tract and medication with hormones, anticoagulants and chemotherapy for cancers need to be excluded.
Menstrual blood flow ceases due to the combined effect of prolonged vasoconstriction, tissue collapse and vascular stasis. The action of platelets and fibrin makes blood loss in menstruation self limiting. Thrombin generation as a result of extravasation of blood is essential for haemostasis. Thus, individuals with platelet or coagulation deficiency have excessive uterine bleeding3.The prevalence of bleeding disorders among adolescents with AUB has been variously reported as ranging from 10.4%6 to 48%.6,7
Menorrhagia may be the most prominent manifestation of a congenital bleeding disorder. 7
A teenager requiring hospitalization for heavy periods with hemoglobin less than 10 g/dl is more likely to have underlying bleeding disorder than the adult woman. Indeed an underlying coagulation disorder can be found in 1 in 5 girls requiring hospitalization, 1 in 4 with severe menorrhagia and hemoglobin less than 10g/dl, 1of 3 needing transfusion and 1 in 2 presenting at menarche8. The majority of these are platelet related disorders (thrombocytopenia and platelet function disorders) and VWD 9 .A detailed history related to easy bruisability, bleeding at the time of surgery as well as family history of bleeding should be elicited among these adolescents. A standardized screening questionnaire to identify those at risk of bleeding disorders has been proposed 10. Bleeding after trauma is the event most predictive of an inherited bleeding disorder .11
In the population receiving care at MCH Centre, PIMS Islamabad, a tertiary care government facility we are providing care for girls with heavy periods due thrombocytopenia, Glanssmann thrombaesthaenia, Factor V and XIII deficiency in collaboration with the hematology, blood Bank and the physicians.
General health status including pallor, pulse, blood pressure and signs of endocrine dysfunction should be noted. Height, weight and Tanner Staging 12 of pubertal development need to be recorded. The initial investigations are full blood count including platelet count, serum iron studies including ferritin, pelvic ultrasound and pregnancy test.
In girls with acute hemorrhage or with hemoglobin less than 10 g/dl further investigations are coagulation profile including prothrombin time, activated partial thromboplastin time and bleeding time, Von Willibrand factor antigen, ristocetin cofactor activity and platelet function assay. A referral to hematologist is required in selected cases to detect rarer factor deficiencies. To avoid false positives, aspirin and other NSAIDs should be avoided in the two weeks preceding platelet function tests. High vaginal as well as endocervical swab for PID and pap smear may be indicated in the married teenager.
Correction of anemia with oral iron and folic acid supplementation is initiated. Acute adolescent menorrhagia should initially be managed in a similar manner as acute menorrhagia in the older women. Recognizing the extent and severity of blood loss assists in deciding the need of admission, intravenous fluids, blood transfusion and fresh frozen plasma.
The available options of medical treatment are tranexamic acid, an antifibrinolytic used as a first line, in a dose of 1g given 3-4 times daily during heavy bleeding reducing menstrual blood loss by 45-60%.13 Mefenamic acid in a dose of 1g, prescribed three times daily reduces menstrual flow by 30% 14 and is very useful for the associated dysmenorrhoea. It use in adolescents with bleeding disorders should be avoided due to its effect on gastric mucosa.
Progestogens are usually administered cyclically but can also be given continuously. These drugs are the first line treatment in anovulatory DUB usually prescribed from day 15-25. In ovulatory DUB the dosage is from day 5-25 and this is the preferred regimen due to its higher efficacy. Drugs prescribed include oral norethisterone (Primolut-N) 5mg three times daily or oral medroxyprogesterone (Provera) 5-10mg twice daily.15 Injection depot medroxyprogesterone acetate 150mg intramuscularly every three months results in long term amenorrhea.
The standard low dose combined oral contraceptive pill with 30ug ethinyl estradiol (Famila 28, Nova and Lofeminal) reduces menstrual blood loss by 40-50% with the added benefit of providing relief from dysmenorrhoea as well as contraception. 16
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Where bleeding does not respond to once daily standard dose consider a cascade oral contraceptive regimen of 1 pill 4 times daily for 4 days, reduced to 1 pill 3 times daily for 4 days, then 1 pill twice daily for 4 days and finally maintained at once daily till 2 packs completed. This high dose of the COCP often requires concomitant anti nausea medication. On this regimen significant slowing of bleeding should occur within two to three days. The use of extended cycling of the low dose combined oral contraceptive pill OCP e.g. tricycling with continuous administration of the active 30ug ethinyl estradiol containing tablets for 12 weeks without a pill free interval is very useful in teens with bleeding disorders.17
Danazol and Gestrinone although effective are seldom prescribed in this age group due to androgenic side effects. GnRH analogues although effective in inducing amenorrhea are not prescribed longer than 6 months due to risk of bone demineralization. Levonorgestrel releasing IUCD (Mirena) may be considered among the teenagers not responding to other medical treatments as its use in adults with known bleeding disorders results in reduction of blood loss in up to 96% and amenorrhea in more than half of treated women. 18
In teenager presenting with acute bleeding, there is no agreement on the most appropriate approach. Intravenous premarin results in more effective reduction and cessation of blood loss than placebo. 19 Yet this option is not readily available in Pakistan. Evidence suggests that there is no additional benefit of intravenous over oral therapy. The use of an inflated balloon of foley catheter as well as uterine artery embolization can be considered 20 for life threatening hemorrhage unresponsive to medical treatment.
In conclusion, majority of adolescents presenting with heavy menstruation are found to have dysfunctional uterine bleeding secondary to anovulation that is easily treatable. Failure to respond in an expected fashion in 3-6 months or anemia at presentation needs investigation for a bleeding disorder. Bleeding disorders require long term follow up, treatment and care along with continuing health education of the teenager as well as her family. Pelvic pathology is indeed very uncommon. There is a need for further studies to develop a consensus in management approaches for this age group.
References
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