Treatment of abnormal menstrual bleeding in adolescents
Dr Bedei, Dr Delisle, Dr Hofmann-Werther, and Dr Pour Mirza highlight how to treat abnormal menstrual bleeding in adolescents.
Dr Ivonne Bedei
Specialist Obstetrics and Gynecology, Fetal Medicine, Pediatric and Adolescent Gynecology, Maternal and Fetal Medicine at Klinikum Frankfurt Höchst, Germany, Mannheim University, Germany, Feto Maternal & GenetYX Center Dubai UAE.
Dr Birgit Delisle
Specialist Obstetrics and Gynecology, Pediatric and Adolescent Gynecology.
Frauenärztin/ Kinder- und Jugendgynäkologie (IFEPAG).
Dr Amelie Hofmann-Werther
Specialist in Obstetrics and Gynecology, Cervical Dysplasia and Colposcopy, Master Class in Fetal Medicine, Feto Maternal & GenetYX Center Dubai, UAE.
Dr Afshin Pour Mirza
Specialist Obstetrics and Gynecology, Fetal Medicine, Feto Maternal & GenetYX Center Dubai, UAE.
Menstrual disorders are very common in female adolescents. It is important to distinguish between physiological and abnormal bleeding. Heavy and painful menstruation and the persistent dysfunctional juvenile bleeding require investigation and appropriate therapy. Common causes are hormone dysfunction and coagulation disorders. Other reasons like structural anomalies are rare, but still have to be ruled out. Treatment options are hormones, antifibrinolytic drugs, and nonsteroidal antiphlogistics. Dysmenorrhea is usually primary and associated with normal ovulatory cycles and without pelvic pathology, but it is important to rule out malformations or endometriosis. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and behavioural changes are the preferred initial treatment options for dysmenorrhea in not sexually active adolescents, otherwise oral contraceptive oral pills can be a reasonable option, even more, if contraception is needed.
Abnormal menstrual bleeding in adolescents: Introduction
Menstruation is an important aspect in the life of an adolescent girl. Still for many teenagers and also their parents it is not clear which bleeding pattern is normal and what is considered to be abnormal and may require treatment. Most adolescent girls tend to have irregular bleedings and a tendency for prolonged menstrual cycles in the first two years after menarche. Anovulation is frequent in these early gynaecologic years and still if ovulation is happening, production of progesterone may still be unbalanced. After maturation of the hypothalamus-hypophysis-ovary axis normal menstrual cycles are going to evolve. That process can take up to 5-6 years. In a normal menstrual cycle bleeding lasts less than 7 days and daily blood loss is about 30-40 ml. Normal cycle length is between 21-45 days.1
Table 1. What is normal?
Abnormal uterine bleeding
A bleeding is considered to be abnormal when:
- It is too heavy (hypermenorrhea), change of big sanitary pads every 1-2 hours, clots.
- It lasts too long (menorrhagia).
- In comes without any regular bleeding pattern (AUB/DUB).
Possible reasons could be qualified in the PALM-COEIN classification2-4
Fig 1 FIGO classification of abnormal uterine bleeding and possible aetiologies PALM- COEIN2-4
Between 10-62 % of adolescent girls suffering from heavy or prolonged menstrual bleedings have a coagulation problem. The most frequent heritable problem is von-Willebrand-Jürgens- Syndrome. This coagulation disorder causes a qualitative or quantitative defect in the production of vWF. In addition to a generally increased bleeding diathesis these girls suffer from heavy menstrual bleeding with dysmenorrhea, ovulation bleeding and irregular bleeding. They also have a higher risk of bleeding in the ovary. Other reasons could be between others thrombozytopenia and impaired platelet function.5
One of the most frequent reasons for abnormal menstrual bleeding in adolescent is ovarian dysfunction based on immaturity of the hypothalamus-hypophysis-ovarian axis with persistence of ovarian follicles and insufficient transformation of the endometrium leading to dysfunctional uterine bleeding. Hyperandrogenic states like PCOS, leading more often to oligo-/amenorrhea, may also lead seldom to dysfunctional and heavy menstrual bleeding.
Less frequent reasons: endometritis (e.g. Chlamydia infection), copper IUP, hormonal therapy, drugs.
General physical examination: weight and height, blood pressure, tanner stage, haematomas or bruising, signs of hyperandrogenism (acne, hirsutism)
In sexually active girls a gynaecologic examination may be considered.
Ultrasound: generally, ultrasound is performed trans abdominally. The bladder should be filled in order to obtain a sufficient view. Uterus and adnexa should be evaluated.
Depending on history and physical findings further testing can be added:
- Pregnancy test should always be performed.
- Test for STI can be considered, depending on history.
- Blood count coagulation analysis.
- Hormone profile (3.-6. cycle day, in the morning before breakfast): LH, FSH, TSH, estradiol, testosterone, DHEAS and prolactin.
Irregularities in the first 2a after menarche are normal and need no further investigation or treatment. Treatment is warranted if intervals between menstruations are less than 20 days or over 3 months, prolonged bleeding and hormonal disturbances (Hyper-/hypothyroidism, hyperandrogenism, PCOS, etc.)
As most menstrual abnormalities in adolescence are based on hormonal problems, a hormonal therapy often is the treatment of choice. If contraception is needed, hormonal contraceptives like combined contraceptive pill or Mirenaâ can be used.
Treatment is divided in acute treatment and long-term treatment options.
Therapeutic goal in acute treatment is to stop bleeding as soon as possible in order to stabilize the circulation of the patient and prevent severe anaemia.5
Most frequent reason is anovulation with follicle persistence. Chronic exposition of the endometrium to estrogen without transformation leads to, sometimes heavy and long lasting, break through bleedings.6
Therapy depends on endometrium height:
- Endometrium > 5 mm: gestagen treatment (e.g. CMA 2-4 mg) for 14 days followed by a combined estrogen-gestagen therapy for 10 days.
- Normally, in prolonged bleeding (> 3 weeks), there is a lack of estrogen, the endometrium is small (< 5mm). treatment options in these cases are an estrogen mono therapy (e.g. estradiol 2 mg), for 10 days, followed by a combined contraceptive pill (e.g. 30 mg EE+ Dienogest). In cases of anemia sometimes treatment has to be started with 2-3 pills/day. If bleeding stops, the pill should be maintained for 6-9 weeks without interruption (long-cycle), to stabilize the hemoglobin levels (off label use). Iron substitution may be necessary.
- In severe drop of hemoglobin levels or orthostatic dysregulation, inpatient care is needed. In severe cases, hormonal therapy can be combined with tranexam acid. Iron supplementation, NSAP (Naproxene 500-1000 mg) can be added. After bleeding stops, hormonal therapy should be maintained for at least 3 months.7
- Cyclic gestagen (anovulatory cycles with heavy menstrual bleeding): CMA 2-4 mg/d or MPA 20-80 mg/d) for 12-14 days. If necessary, this can be extended up to 20 days.
- Continuous gestagen (suppression of menstruation in cases of anemia): continuous intake of CMA 2-4 mg or MPA 20-40 mg. This leads also to suppression of ovulation. If there are contraindications for estrogens and contraception is needed in addition, a POP (progesterone only pill) can be used. Combined estrogen and gestagen lead more often to a better control of bleeding. LNG IUPs may be used as an alternative. The most effective one being Mirenaâ. Patients have to be counselled that irregular bleeding can occur in the first 3-6 month of use.
Nonhormonal treatment options:
- Nonsteroidal antiphlogistics (NSAP) may reduce bleeding by interaction with prostaglandine synthesis
- Tranexam acid may be indicated in heavy bleedings.3
Table 2: Therapeutic options in AUB (adapted after: Williams C.E., Creighton S.M.8
Menstruation irregularities in the first two years after menarche are normal in most cases and do not need any further treatment or investigation. In cases of heavy or prolonged bleeding, a coagulation disorder should be ruled out. Hormonal treatment or antifibrinolytic drugs may be treatment options.
Credit: The article is part of a publication in Monatsschrift Kinderheilkunde.