Maria C. Monge, MD
Director of Adolescent Medicine
Dell Children’s Medical Center
UTSW-Austin Pediatrics Residency Program
Lone Star Circle of Care

• I have no relevant financial disclosures.

• 1. Define abnormal uterine bleeding (AUB) in an adolescent.
• 2. Discuss possible etiologies of AUB in an adolescent and use these in consideration of the the initial outpatient workup of AUB.
• 3. Identify initial outpatient management strategies for adolescents with AUB.

• Madeline is a 12 year old who comes to your office after she felt lightheaded at school.
– Mom called and triage nurse said to bring her in.
– Mom told the nurse that Madeline has had menstrual bleeding for more than 1 week and has been feeling more tired than usual for the past month.

• Review of records before she arrives
– Healthy, on no medications
– Growth and development normal
• 50% BMI
• At last WCC had not started menstruating, but had
SMR3 breasts and pubic hair
– Family history unremarkable

• Menarche: 2.3y after pubertal initiation
– Range 1-3 years
• Cycle length: 21-42 days (beginning to beginning)
– Should be regular by 2-2.5 years
– Cycles outside of 20-45 days should be considered abnormal even in adolescents
• Duration: 3-7 days
• Average blood loss: 30 mL/cycle
– Can be 20-80mL

• 55-82% of adolescents take up to 24 months after menarche before having regular ovulatory cycles
– Adolescents with later onset of menarche have longer intervals until cycles become ovulatory
– Immaturity of HPO axis
• Having an occasional ovulatory cycle stabilizes endometrial growth and allows for complete shedding

• On arrival to office -- History
– In the midst of her 3 rd menstrual period
• First one about 4 months ago and was light, lasted 5 days; Second one about 2 months ago and was moderate flow lasting 7 days
– Started 8 days prior
– Soaking pads every 1-2 hours

• Proposed screening questions
– Period lasting > 7 days
– Feeling of “flooding” or “gushing” most cycles
– Activities limited by periods
– Bleeding “problem” after dental extraction, surgery or delivery/miscarriage
– Family history of bleeding disorder

• ROS: feeling tired, maybe easy bruising but not sure, no acne or hirsuitism
• Medications: None
• Family History: Mom menarche age 13 and was irregular for 1-2 years
• Social history: Lives with Mom, in 6 th grade, has a boyfriend but no sex, no trauma, no foreign bodies in vagina

• Anovulatory uterine bleeding
• Endocrine disorders
• Bleeding disorders
• Pregnancy-related complications
• Infection
• Hormonal contraception
• Use of IUDs
• Medications
• Vaginal, cervical or uterine carcinoma, sarcoma, polyps
• Cervical hemangioma
• Congenital uterine abnormalities
• Vaginal lacerations, trauma
• Endometriosis
• Foreign body

What is on our differential for
Madeline?
• Systematic approach
• Consider pertinent history and physical

What is on our differential for
Madeline?
• Systematic approach
– Prolactinoma
– Thyroid Disease
– Cushings, CAH
– PCOS, Anovluation,
Pregnancy, POI,
Trauma, Infection,
Polyp
– Bleeding Disorder

• Key points
– Vitals , Height, Weight, BMI
– Features of endocrinopathies
• Androgen excess
• Cushingoid
• Thyroid
– Other signs of bleeding
– GU exam
• Minimum is external
• Pelvic exam-most girls who have used tampons can tolerate a 1 finger digital exam to check for foreign bodies

• Vital Signs: BP 98/66 HR 72 T 98.4 BMI 75th%
• Gen: slightly pale and anxious-appearing
• Neck: no thyroid enlargement
• CV: soft SEM at RUSB
• Chest: SMR4 breast
• Abd: soft, NT/ND, no striae
• GU: SMR 4 pubic hair, external exam without evidence of trauma, +bleeding from vagina
• Skin: no hirsuitism, acne, acanthosis, petechiae, bruising

• Anything move up or down the list?

• CBC with differential
• B-hcg (sensitive urine or serum)
• TSH, free T4
• Type and Screen
• FSH, LH, prolactin, free/total T, DHEA-S
• PT/PTT, von Willebrand panel
• GC/CT testing

• CBC: Hemoglobin 10.4 g/dL, remainder normal
• Urine hcg: negative
• TSH: 255 mIU/L, T4 0.5 mcg/L
• Von Willebrand Panel:
– VW Factor 90% (50-160 normal)
– Factor XIII 142% (70-170 normal)

• Many factors impact VWF levels
– Ideal to test off of hormones or on Day 7 of placebos
• VWD <30% activity now considered diagnostic
– 30-50% is “low von Willebrand factor”
• Consider screening as not uncommon in adolescents with menorrhagia
– Estimates vary widely in literature with many suffering from selection bias

• Consider if:
– Unable to do pelvic exam
– Prolonged bleeding despite treatment
– Pelvic mass or uterine anomaly suspected

• Stop bleeding
• Treat underlying condition (if applicable)

• All patients should keep a menstrual calendar
• Ensure iron stores are addressed, even if Hgb normal.
– Patients typically need several months of oral iron to replete stores

• Off-label use
• Monophasic
• Potent progestin
– Norgestrel (0.3mg)
• Ex. Lo/Ovral, Low-Ogestrel, Cryselle
– Levonorgestrel (0.15mg)
• Ex. Nordette, Levlen, Levora, Portia
Note: Naming brand names does not imply endorsement of a particular product

Treatment depends on current bleeding and Hgb
•
– Menses slightly prolonged or cycle slightly more frequent
– Normal hemoglobin
• This can be distressing to patients and families
• May observe for several cycles
– Iron supplementation
– Naproxen or Ibuprofen
• Anti-prostaglandins have been reported to decrease blood loss
• May consider treatment with OCP or progestin

Treatment depends on current bleeding and Hgb
– Menses >7d or cycle frequency <3 weeks and mild anemia (Hgb 10-11g/dL)
• If patient not bleeding significantly at time of visit and is not already on hormonal therapy can start with 1 pill daily
• If patient with moderate bleeding at time of visit,
1 pill BID until bleeding stops, then daily for total of 21 days
– Continue cyclic pills or may do continuous
• Follow Hgb as needed
– Consider continuing pills at least until Hgb normal
(min 3-6 months)

Treatment depends on current bleeding and Hgb
•
– Ongoing heavy bleeding with moderate anemia
(Hgb 8-10g/dL)
• If bleeding is slowing and Hgb >9 g/dL
– Can start with BID pills (see moderate)
• If bleeding not slowing
– 1 pill q6h for 2-4 days
• prn anti-emetic 2h before pill
– 1 pill q8hx 3 days
– 1 pill q12h for at least 2 weeks
• Follow serial Hgb closely
• Consider inpatient admission if concern for patient/family reliability

Treatment depends on current bleeding and Hgb
•
– Ongoing heavy bleeding, Hgb ≤ 7g/dL, Orthostatic vital signs
– Admit for inpatient management
– Notes
• Decision to transfuse not based solely on number
• Most patients can be managed with OCPs
• D&C rarely indicated

What if patient has contraindication to estrogen?
• Medroxyprogesterone
– Short courses in mild bleeding
– Cyclic therapy if need ongoing
• Norethindrone acetate
– Short courses in mild bleeding
– Cyclic therapy
– Continuous menstrual suppression
• LNG-IUS

When should referral be considered?
• To ER
– Symptomatic anemia
– Vital sign abnormalities
• To Adolescent Medicine/Reproductive
Endocrinology
– OCP complications or decisions
– Bleeding difficult to control (breaking through)
– Secondary cause identified

• Remember what is “normal”
• Differential broad
• History is important
– Menstrual history as a “vital sign”
• CBC to guide treatment
• Different treatment options exist

Contact information:
Maria C. Monge, MD
Director of Adolescent Medicine
UTSW-Austin Pediatrics Residency Program
312-498-3470 mcmonge@hotmail.com