Abnormal Uterine Bleeding in Adolescents

Elisabeth H. Quint, MD, Yolanda R. Smith, MD

Disclosures

J Midwifery Womens Health. 2003;48(3) 

In This Article

Treatment of Aub

The goals of therapy for AUB in adolescent women are threefold. The first goal is to assess how serious the abnormal bleeding is, while ruling out any anatomic or pathologic causes. The second goal is to find out what her expectations and needs are. It is important to realize that often adolescent women may have a different goal for an office visit than she articulates to her parents or office staff; for example, she may have a need for birth control more than she needs regulation of her cycles. The third goal is to educate about normal irregular bleeding in adolescents. If she is not anemic or does not have symptoms that warrant a referral for medical evaluation and she does not need birth control, then reassurance and education may be all the treatment required. Prospective charting of menses will help to document cycle frequency.

Although anovulation is very common in teens, excessive bleeding leading to anemia is uncommon. The WHO study of adolescent menstrual patterns found only 5% of bleeding lasted more than 7 days, and only 0.5% lasted more than 10 days.[7] The goals of therapy for menorrhagia, once pathology has been ruled out, are to: 1) stop the bleeding, 2) restore synchrony to the endometrium, and 3) replenish iron stores. Most often, this can be achieved with estrogen and/or progesterone therapy. Table 2 outlines a systematic approach to management of dysfunctional uterine bleeding in adolescents, based on symptoms and hemoglobin level.

Hemoglobin is Normal or >10 g/dl

If the bleeding is irregular, but not heavy enough to cause disturbance of the normal activities, reassurance and education should be offered. Prostaglandin inhibitors (ibuprofen or mefenamic acid), which alter the balance between thromboxane and prostacyclin, may relieve cramping and reduce flow volume by 20 to 50%.[24] Oral contraceptives will establish regular menses and regulate blood loss. Adolescents with DUB should be offered this treatment option, which should be explored with the adolescent in a private conversation. Some parents are uncomfortable with adolescents being on "the pill," and it is important to provide thorough information about side effects and non-contraceptive benefits. Anticipatory education about side effects and consistent self-administration are important, because the discontinuation rate in adolescents is high.[25]

A pelvic examination and Papanicolaou smear are not absolutely necessary to prescribe birth control pills. Expert consensus developed in the last decade supports initiating hormonal therapy in adolescents as safe when based on a careful review of medical history and blood pressure measurement alone. Performing a Papanicolaou smear and pelvic examination is important to screen for STIs and cervical cancer in women prior to prescribing oral contraceptives for birth control, but these examinations do not provide information necessary to identify women who should avoid hormonal contraceptives.[26] However, it is important to emphasize that oral contraceptives do not protect against STIs.

Hemoglobin <10, But No Active Bleeding

If the patient is clearly anemic, oral contraceptives are the treatment of choice, and a 30- or 35-mcg preparation is usually adequate. Because restoration of synchrony is a goal of therapy, a monophasic preparation is preferred. Oral contraceptives and prostaglandin inhibitors both reduce menstrual flow in patients with a normal uterus. Supplemental iron should be encouraged. Reevaluation in 3 to 6 months is recommended. The length of treatment should be dependent on the severity of the anemia but will generally be 1 to 2 years (or as needed for contraception).

Progestins alone are also an effective treatment for anovulatory bleeding. Medroxyprogesterone acetate (Provera) may be prescribed in a dose of 5 to 10 mg per day or micronized progesterone (Prometrium) 100 to 200 mg per day for 10 to 14 days, starting on day 16 of the cycle, to induce stromal stability, which is then followed by a withdrawal flow. Disadvantages of this treatment are that the patient is not protected from pregnancy if she is sexually active and irregular bleeding can occur if the patient ovulates. In addition, cyclic progestins, unlike oral contraceptive pills, will not reduce acne or stop the progression of hirsutism, if these are concomitant problems. The side effects of the progestins can include moodiness, depression, and weight gain.

Hemoglobin <10, With Active Bleeding

If the patient had prolonged bleeding and is still bleeding at the time of her visit, but is hemodynamically stable, outpatient therapy with short-term follow-up is adequate. Prolonged asynchronous breakage and shedding results in a thinned endometrium (measurable by ultrasound) and will require higher doses of estrogen to rebuild tissue and replace progesterone receptor sites. Progestin therapy alone will generally not stop the bleeding in this case. Physician consultation is advisable. A cascade of oral contraceptives is started as soon as possible, if the client has no contraindications to the use of estrogen. This should be a 30- or 35-mcg ethinyl estradiol monophasic pill, to be given at high doses with a slow decline. An easy formula is one pill qid for 4 days, then one pill tid for 4 days, then one pill bid for 4 days, then one pill qd. Antinausea medication needs to be offered as part of this regimen, because some patients will not be able to tolerate the high doses of estrogen. With this cascade, the client should have significant slowing of the bleeding in 48 to 72 hours and should be instructed to call if this is not the case or if the dosage is not tolerated. Once the cascade regimen is completed, the severity of the bleeding and the degree of anemia will dictate how long oral contraceptive use is recommended at regular dosing intervals. Recent studies indicate that prolonged episodes of continuous oral contraceptives are efficacious in the treatment of menorrhagia.[27] If the patient has a contraindication to estrogen, an acute physician referral should be obtained. Depot medroxyprogesterone is an alternative if long-term amenorrhea is desired.

Acute Hemorrhage

Refer immediately to physician for admission and treatment. Often intravenous estrogen is used. Surgery is rarely indicated.[11]

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