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 6 th gynecologic year (ages 19-20)
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
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
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. 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.
The most significant initial lab test for evaluation of menorrhagia in young women is: 1. TSH 2. Platelet function screen 3. Prolactin 4. 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. Anovulatory cycles 2. Hypothalmic disorders 3. Athletic activities 4. 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= 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 –C–Correct endocrine disorder –R–Rx chronic medical conditions (diabetes / liver dz / renal failure) -Exclude bleeding disorders 2. Based on individual need –C–Contraception / Acne / Hirsutism
Evaluation of acute Menorrhagia/Hemorrhage 1. Asses current Hgb and hemodynamic status –A–Admit if Hgb < 7 gm –A–Admit if orthostatic or other medical conditions 2. Obtain: clotting studies complete metabolic profile pertinent 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
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.
Options for Management of Acute Menorrhagia (Hemorrhage) in Young Women Include: 1. Intravenous conjugated estrogen 2. Combined hormonal contraceptive regimens 3. Both 4. Neither
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 packing Endometrial ablation, uterine artery embolization or hysterectomy are not appropriate for adolescent women
6. Adjuvant Therapies a. Aminocaproic acid (antifibrinolytic) b. Desmopressin (arginine vasopression analog) c. Tranexamic acid (anti fibrinolytic)
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
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. 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
Long-term management of menses in women with bleeding disorders include: 1. Continuous combined estrogen and progesterone oral contraceptives 2. Levonorgestral IUD 3. Depo medroxyprogeste rone acetate 4. All of the above
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