Management of Heavy Menses in Adolescent Women

1. Management of Heavy Menses in Adolescent Women Janice L. Bacon, M.D.

2. DISCLOSURE I have no financial relationships with any commercial interests related to the content of this activity today.

3. 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

4. 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 intervals • Woolcock etal. Fert and Stertliny – 2008; 6: 2269 • Higham BrJ Obstet. Gynsecol 1990; 97: 734

5. Population Statistics • Population Statistics: 10-35% women report Menorrhagia • 21-67% develop iron deficiency anemia

6. Healthy Adolescents Anovulation Endocinopathy Bleeding disorder Teens with Chronic disease Malignancy/Chemotherapy Medication effects Solid organ transplant Stem cell transplant Overview of Etiology **Always exclude Pregnancy!

7. 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)

8. 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.

9. 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

10. 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

11. Laboratory Tests – Menorrhagia **Hgb/Hct is the most important discriminating test! • 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.

12. The most significant initial lab test for evaluation of menorrhagia in young women is: • TSH • Platelet function screen • Prolactin • CBC

13. Management:Menorrhagia without Anemia Most common etiology = anovulation Order laboratory tests based on medical history Management Strategies Immediate: Menstrual Regulation (3-6 mos) Monthly Progesterone Micronized P 400 mg qhs x 10 days Medroxyprogesterone acetate 20 mg/d x 10 days Cyclic hormonal contraception Progestin – only ocp’s E + P Ocp’s NSAIDS

14. Common causes of menorrhagia (without anemia) in adolescent women include: • Anovulatory cycles • Hypothalmic disorders • Athletic activities • All of the above

15. Management Strategies Long term: Menstrual Calendar: Consider other medical needs: • Contraception • Acne/Hirsutism Uncontrolled bleeding or recurrent episodes many prompt future evaluation

16. 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 Medical Evaluation:

17. Management Strategies: Menorrhagia + AnemiaImmediate: Control Bleeding Noncyclic hormonal therapy • Combined E + P methods • Pills • Vaginal ring • Patch • 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 ) • Adjuvant Therapy • Antiemetics • NSAIDS • Tranexamic acid

18. Management Strategies: Menorrhagia + AnemiaLong Term Management • Based on diagnosis • Correct endocrine disorder • Rx chronic medical conditions (diabetes / liver dz / renal failure) - Exclude bleeding disorders • Based on individual need • Contraception / Acne / Hirsutism

19. Evaluation of acute Menorrhagia/Hemorrhage • 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

20. Management of Acute Bleeding • 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.

21. Options for Management of Acute Menorrhagia (Hemorrhage) in Young Women Include: • Intravenous conjugated estrogen • Combined hormonal contraceptive regimens • Both • Neither

22. 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

23. Adjuvant Therapies • Aminocaproic acid (antifibrinolytic) • Desmopressin (arginine vasopression analog) • Tranexamic acid (anti fibrinolytic)

24. Long Term Management of Adolescent Women with Bleeding Disorders • 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

25. 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

26. Adjunctive Medications • 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

27. Long-term management of menses in women with bleeding disorders include: • Continuous combined estrogen and progesterone oral contraceptives • Levonorgestral IUD • Depo medroxyprogesterone acetate • All of the above