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Dysfunctional Uterine Bleeding

Diane Tanaka, MD, Solomon Behar, MD, and Mizuho Morrison, DO

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Review the diagnostic workup of dysfunctional uterine bleeding in adolescents.

Background and Definitions

There has been some change to terminology in the last few years. ACOG has redefined the terms after they got sick of pediatricians misusing Menometrorrhagia. Older terminology is noted in italics below. 

A good summary of the changes is listed here:

What is the current average age of menarche?

  • 12.4 years, 6 months earlier for African Americans and Latinos. This is down from 12.8 years with some girls having their first periods as young as 9 or 10 years old.
    • Etiology is not known. Theories about nutrition and hormone exposure in cosmetics and meats exist with demonstrated associations but not established causality.

When should parents be doing the menarche talk?

  • Dr. Tanaka recommends the talk at Tanner stage 3 breasts giving an average of 6 months to menarche.

When are periods too frequent or infrequent? 

  • This is measured from first day of menses to first day of next menses.
  • The average is 28-30 days.
  • Too frequent
    • Less than 21-24 days (previously known as polymenorrhea).
  • Too infrequent (previously known as hypomenorrhea).
    • More than 45 days for teenagers.
    • Adult women more like 40 days.

How much is too much? How much is too little?

  • Average blood loss is 30-40cc per cycle.
  • Too little is less than 20 cc’s.
  • Heavy menstrual bleeding (previously known as menorrhagia) is more than 80 cc’s.
    • 80 cc’s is about 4 soaked pads a day. Keep in mind that many teens will change pads after only a little bit of bleeding so that word soaked is very important here.
    • It is best defined by the patients perception of the amount of bleeding.

A few more terms to know

  • Bleeding between periods- Inter-menstrual bleeding (this replaces Menometrorrhagia)
  • Painful periods- Remains dysmenorrhea.
  • The diagnosis of exclusion for heavy bleeding or prolonged bleeding previously dubbed dysfunctional uterine bleeding (DUB) is now referred to as abnormal uterine bleeding (AUB).

Workup for heavy menstrual bleeding

Who needs to be worked up for bleeding more than is expected?

    • Very first period was heavy 
    • Passing clots
    • Bleeding necessitating a blood transfusion

What is the first line work-up?

  • CBC looking for platelet count (ITP or other etiology of thrombocytopenia) and assessing for anemia.
  • PT/PTT looking for coagulopathy.
  • TSH a good test as adolescence is a common age for presentation of thyroid disorder.
  • Pregnancy test for complications of pregnancy. 
  • If the clinical picture fits Polycystic Ovarian Syndrome (PCOS): 
    • Free testosterone.
    • Total testosterone.
    • Considering LH and FSH to evaluate for ovarian insufficiency. 

Who needs imaging and what imaging is needed?

  • Imaging should be done for:
    • Patients in whom you are looking for polycystic ovaries.
    • Patients with heavy bleeding despite treatment. 
    • Patients with very painful periods.

What are the special concerns for a virginal patient?

  • You can still get an ultrasound but trans-abdominal not trans-vaginal.
  • You should still get the pregnancy test as patients may be afraid to mention abuse or incest.
  • Evaluation for sexually transmitted infections would depend on symptoms.
    • Discharge from the vaginal area, an abnormal odor or painful urination may trigger evaluation.
  • The virginal patient has a more narrow differential diagnosis which raises the concern for a bleeding disorder.
  • Ask about retained foreign body (like a tampon).
  • Ask about masturbation as an etiology of trauma.  With suspicion of trauma an internal exam should be done.
    • The exam can be done with a virginal speculum especially in tampon users.
    • If she refuses exam a first pass at medical management can be started and reserve the exam for failure of medical management. At the minimum an external exam should be performed. 

Management of heavy menstrual bleeding

Treatment: Dr. Tanaka gives a broad overview of treatment with a variety of options depending on severity. When available a hormone releasing IUD works the best. There has been an “IUD revolution” and it is no longer a no-no to place an IUD in a nulliparous girl as the association with PID and infertility is not seen with the current IUDs. 

IV treatment
  • For admitted patients to promote clotting
  • Conjugated estrogen of 25 mg IV q6h
  • Typically max out at 6 doses to reduce risk of clotting and other side effects In addition need to start a progesterone containing hormone either:
    • Medroxyprogesterone
    • Combined OCP
Combined birth control pill
  • The role of estrogen is to promote clotting and the role of progesterone is to inhibit proliferation of endometrium.
  • When selecting an OCP for this indication you do not need a high estrogen pill but are looking to have at least 30mcg a pill. Initial dosing in the face of heavy bleeding would be 100-120 mcg of estrogen a day (4 pills a day).
  • Dr. Tanaka recommends a monophasic pill. Triphasics, which better simulate normal menstrual cycle with dropping progesterone levels, could lead to a withdrawal bleed with dropping estrogen levels.
  • She uses LoOvral as it is a second-generation progestin (more estrogenic) and gets bleeding to stop quicker. Other second or third generation progestins are options.
Progesterone only medication e.g. medroxyprogesterone
  • Stabilizes endometrial lining.
  • 10mg daily for five to seven days only during the patient’s period.
  • Is not a good option if sexually active, as it does not provide contraception. May be a good option for the virginal girl or those opposed to contraception.
IUD, Implants, “The Ring” are all options
  • Mirena™ a hormone releasing IUD works better than anything else. There is good evidence that it does not increase the risk of PID as progesterone thickens cervical mucus.
  • Similarly Skyla™ is a new progesterone embedded IUD specifically for virginal girl and women.
  • A Copper IUD (aka: Para Gard) is not a good option as it may increase bleeding.

What are your Indications for admission?

  • Hemodynamically unstable with positive orthostatics or hemoglobin < 7.

What are your Indications for transfusion?

  • Dr. Tanaka uses the hemoglobin and platelet count to help make this decision.
  • Patients with Hgb <6 will get transfused.
  • Hgb of 6-8 will not get transfused if the platelet count is normal and just get resuscitation with NS or LR in addition to hormonal treatment.

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These Crazy Kids Are All Elbows and Rashes Full episode audio for MD edition 203:42 min - 96 MB - M4AHippo Peds RAP February 2015 Summary 498 KB - PDF