4 oa ss - texas children's hospital · • outline the normal progression and timing of...

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Oluyemisi Adeyemi-Fowode Texas Children’s Hospital

Abnormal Uterine Bleeding

Objectives •  Outline the normal progression and timing of pubertal development •  Review characteristics of normal and abnormal menses in

adolescent girls •  Review probable causes and workup of abnormal uterine bleeding in

adolescent girls •  Discuss management of abnormal uterine bleeding associated with

ovulatory dysfunction

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Puberty

Stages of Puberty •  Therlache (Breast development) •  Pubarche (Pubic hair) •  Growth Spurt (Peak height velocity) •  Menarche (First menstrual period)

Breast bud

Onset pubic hair

Peak height velocity

Menarche

Adult breast

Adult pubic hair

10.5

11.0

11.4

12.8

14.6

13.7

8 10 12 14 16 18

Age in Years

Mean

Menarche •  Age has remained relatively stable

– Menarche: 12 years – 2-3 years after thelarche

•  Typically at Tanner stage IV – Rare before Tanner stage III

•  Evaluation warranted – Lack of breast development: age 13 – Primary amenorrhea: age 15

ACOG: Menstruation in girls and adolescents: Using the menstrual sign as a vital sign. Obstet Gynecol. 2015 Dec;126(6):e143-6.

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Normal Menstrual Cycles in Adolescent Girls

Menarche (median age) 12.43

Mean cycle interval 32.2 days in first gynecologic year Menstrual cycle interval Typically 21-45 days Menstrual flow length 7 days or less Menstrual product use Three to six pads or tampons per day


Abnormal Uterine Bleeding •  Once menarche is reached, uncommon to remain

amenorrheic for > 90 days •  Mean blood loss per period: 30 ml •  > 80 ml associated with anemia

Discontinuation of the term Dysfunctional Uterine Bleeding (DUB) is recommended Limited clinical use!!!!!

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Abnormal Uterine Bleeding •  Flow requiring changes of menstrual products Q1-2 hrs •  Flow lasting > 7 days at a time

Ask the patient to chart her menses

Technology •  iOS & Android

– Period Tracker – My Cycles – MonthPal – Pink Pad

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PALM-COEIN Classification System Abnormal Uterine Bleeding •  Heavy menstrual bleeding (AUB/HMB) •  Intermenstrual bleeding (AUB/IMB)

PALM–structural causes Polyp (AUB-P)

Adenomyosis (AUB-A) Leiomyoma (AUB-L) •  Submucosal leiomyoma (AUB-LSM) •  Other leiomyoma (AUB-LO) Malignancy and hyperplasia (AUB-M)

COEIN–nonstructural causes Coagulopathy (AUB-C)

Ovulatory dysfunction (AUB-O) Endometrial (AUB-E)

Iatrogenic (AUB-I) Not yet classified (AUB-N)

Working group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3-13

Probable Causes of AUB by Age Group

AH James, et al. European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 124-134.

Cause Adolescent (13-19 years)

20-35 years

35-45 years

Peri/post-menopausal

Anovulatory bleeding in the adolescent Bleeding disorder (known or unknown) Chronic menorrhagia with acute deterioration Local pathology eg, fibroid with necrosis or endometrial polyp Adding of a new systemic disease eg, leukemia

Anticoagulant therapy

Postoperative complication

Hypothyroidism

Perimenopausal anovulation

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Irregular Bleeding •  STIs •  Malignancy •  Uterine Lesions •  Trauma Management of Abnormal Uterine Bleeding

Associated With Ovulatory Dysfunction. Obstet Gynecol. 2013 Jul;122(1):176-85.

Physiologic •  Adolescence •  Perimenopause •  Lactation •  Pregnancy

Pathologic •  Hyperandrogenic anovulation (eg, PCOS, congenital adrenal

hyerplasia, or androgen-producing tumors) •  Hypothalamic dysfunction (eg, secondary to anorexia nervosa) •  Hyperprolactinemia •  Thyroid disease •  Primary pituitary disease •  Premature ovarian failure •  Iatrogenic (eg, secondary to radiation or chemotherapy) •  Medications

Causes of Anovulation

Irregular Menses Panel

•  UPT

•  FSH/LH/Estradiol

•  TSH

•  Prolactin

•  Testosterone panel

•  DHEA-S

•  17-OHP

•  Pelvic US

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Excessive Uterine Bleeding •  Anovulation

•  Von Willebrand’s Disease

•  Liver failure

•  Malignancy

•  Rare hematological conditions – Factor deficiencies –  ITP – Aplastic anemia

Excessive Bleeding • Anticoagulation • Trauma


Heavy Menses Panel

•  UPT

•  CBC

•  TSH

•  PT/INR/PTT

•  Fibrinogen

•  Von Willebrand panel

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AUB-O •  Treatment goals

– Halt abnormal bleeding – Prevent recurrence –  Improve QOL – Avert morbidity – Simultaneously provide contraception

•  AUB-O is an endocrine abnormality

•  Exogenous steroids is an important component

Treatment for AUB-O •  Combined Hormonal therapy •  Progestin therapy

Combined Hormonal Therapy Combined Oral Contraceptives

Transdermal patches Vaginal ring

Progestin Therapy Progestin only Pills

Depot medroxyprogesterone acetate Etonorgestrel Implant Intrauterine Device

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Medical Conditions to Avoid Use of Estrogen •  Uncontrolled hypertension

•  Severe cardiac valve disease

•  Rheumatic disease associated with antiphosphopholipid antibodies

•  Migraines with aura

•  Severe liver disease

•  Personal history of VTE

•  Strong family history of VTE

•  Breastfeeding

•  Major surgery requiring long-term immobilization

U.S. Medical Eligibility Criteria for Contraceptive Use

Oral Contraceptive Pills

Typical failure rate: 9%

Kost K et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception (2008) 77 p. 10-21.

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Contraceptive Patch: Ortho Evra®

•  A treatment cycle consists of the application of 3 patches for 7 days each, consecutively, with a 7 day patch-free phase

•  Decreased efficacy at higher BMI i.e. >198 lbs (90 kg)



Depot Medroxyprogesterone Acetate •  Depo Provera® 150 mg injected IM or 104 mg

SQ q 12 weeks

•  Most common side effects are: –  Irregular bleeding – Weight gain – Decreased bone density



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Long-Acting Reversible Contraception •  Contraceptive implants

– Nexplanon®

•  Intrauterine devices – Paragard®

– Mirena®

– Skyla®

•  Preferred method per AAP, ACOG •  Most common side effect is irregular bleeding

Typical failure rate: <1%


4 oa ss - texas children's hospital · • outline the normal progression and timing of...

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