Bacon-ManagementofHeavyMenses

Report
Management of Heavy Menses
in Adolescent Women
Janice L. Bacon, M.D.
DISCLOSURE
I have no financial
relationships with any
commercial interests
related to the content of
this activity today.
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
Terminology

Abnormal uterine bleeding (AUB)


Menorrhagia (Hypermenorrhea)



Bleeding which is excessive or occurs outside of normal
menses
Menstrual blood loss >80 ml/cycle
Document #pads/tampons (or both) and saturation
Metrorrhagia

Irregular, frequent bleeding intervals
1.
Woolcock etal. Fert and Stertliny – 2008; 6: 2269
Higham BrJ Obstet. Gynsecol 1990; 97: 734
2.
Population Statistics

Population Statistics: 10-35% women
report Menorrhagia

21-67% develop iron deficiency anemia
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!
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)
Menstrual Parameters





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.
Menorrhagia – Pertinent Facts


Menstrual calendar – paper or smart phone apps!
Symptoms of endocrinopathy:
–
–

Systems of bleeding disorders
–

Weight change, acne, facial or body hair
Heat/cold intolerance, breast development, galactorrhea
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
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
Laboratory Tests – Menorrhagia
**Hgb/Hct is the most important discriminating
test!
1.
2.
3.
This may need to be checked before and after
menses
Hgb <10 gms prompts further evaluation
Prior Hgb levels for comparison maybe helpful!
**Assess hemodynamic stability when acute
bleeding present.
The most significant initial lab test
for evaluation of menorrhagia in
young women is:
1.
2.
3.
4.
TSH
Platelet
function
screen
Prolactin
CBC
Management:
Menorrhagia without
Anemia
Most common etiology = anovulation
Order laboratory tests based on medical history
Management 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 contraception
Progestin – only ocp’s
E + P Ocp’s
3.
NSAIDS
Common causes of menorrhagia
(without anemia) in adolescent
women include:
1.
2.
3.
4.
Anovulatory
cycles
Hypothalmic
disorders
Athletic
activities
All of the
above
Management Strategies
Long term:
Menstrual Calendar:
Consider other medical needs:
–
–
Contraception
Acne/Hirsutism
Uncontrolled bleeding or recurrent episodes
many prompt future evaluation
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
Management Strategies:
Menorrhagia + Anemia
Immediate: Control Bleeding
Noncyclic hormonal therapy
1.
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
Management Strategies:
Menorrhagia + Anemia
Long Term Management
1.
Based on diagnosis
–
–
2.
Correct endocrine disorder
Rx chronic medical conditions
(diabetes / liver dz / renal failure)
Exclude bleeding disorders
Based on individual need
–
Contraception / Acne / Hirsutism
Evaluation of acute
Menorrhagia/Hemorrhage
1.
2.
3.
4.
5.
Asses current Hgb and hemodynamic status
–
Admit if Hgb < 7 gm
–
Admit if orthostatic or other medical conditions
Obtain:
clotting studies
complete metabolic profile
pertinent endocrine studies
Draw labs for bleeding disorder if new event and transfusion
pending
Assess pelvic anatomy (USG)
Occasionally an exam under anesthesia and D&C may be
needed
Management of Acute Bleeding
1.
2.
3.
E + P hormonal contraceptive tablets every 4 hrs.
(usually 4-8 tabs)
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
Transfusion of Blood products
Dr. Vore, et al. Obstet Gynecol (1982) 59; 285.
Options for Management of Acute
Menorrhagia (Hemorrhage) in
Young Women Include:
1.
2.
3.
4.
Intravenous
conjugated
estrogen
Combined
hormonal
contraceptive
regimens
Both
Neither
4.
5.
6.
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
Dilatation and curettage
–
If bleeding uncontrolled after 24 – 36 hrs
Endometrial balloon or packing
Endometrial ablation, uterine artery embolization or hysterectomy
are not appropriate for adolescent women
6.
Adjuvant Therapies
a.
b.
c.
Aminocaproic acid (antifibrinolytic)
Desmopressin (arginine vasopression analog)
Tranexamic acid (anti fibrinolytic)
Long Term Management of Adolescent
Women with Bleeding Disorders
1.
2.
Combined E + P contraceptive regimens
–
Noncyclic
–
Monophasic 30-50 mg estrogen regimen may be most successful
–
Vaginal ring and patch also good choices
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
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
4.
Adjunctive Medications
a.
b.
c.
Aminocaproic acid (5g) initially, then 1000 mg
every hour x 8 (or 4-5 doses)
Desmopression 0.3 mg/kg IV – repeat in 48 hrs.
Tranexamic acid 650 mg – 2 tabs TID
Long-term management of menses
in women with bleeding disorders
include:
1.
2.
3.
4.
Continuous
combined
estrogen and
progesterone oral
contraceptives
Levonorgestral
IUD
Depo
medroxyprogeste
rone acetate
All of the above

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