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Swaminathan N, Sharathkumar A, Dowlut-McElroy T. Reproductive Tract Bleeding in Adolescent and Young Adult Females with Inherited Bleeding Disorders: An Underappreciated Problem. J Pediatr Adolesc Gynecol 2022; 35:614-623. [PMID: 35830928 DOI: 10.1016/j.jpag.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
Reproductive tract bleeding is an underappreciated health care problem among adolescent and young adult (AYA) females with inherited bleeding disorders (IBDs) comprising von Willebrand disease, platelet disorders, hemophilia carriership, and rare factor deficiencies. IBDs are prevalent in women of all ages and have been detected in about 50% of women with menorrhagia or heavy menstrual bleeding (HMB) and about 20% of women with postpartum hemorrhage (PPH). The clinical spectrum of gynecologic and obstetric bleeding in AYA with IBDs ranges from HMB, ovulation bleeding, and surgical bleeding to miscarriages and life-threatening PPH. Reproductive tract bleeding adversely affects the quality of life of this patient population, in addition to causing substantial morbidity and mortality. Early diagnosis of IBDs offers the opportunity for timely intervention with hormones, hemostatic agents, and prophylaxis with factor concentrates, thereby improving outcomes. This review summarizes the epidemiology, pathophysiology, clinical manifestations, diagnostic approach, management, and prophylaxis for reproductive tract bleeding in AYA with IBDs. This review provides a multidisciplinary approach to the problem, which is critical to improve the outcomes of this patient population.
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Affiliation(s)
- Neeraja Swaminathan
- Division of Pediatric Hematology Oncology, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Anjali Sharathkumar
- Division of Pediatric Hematology Oncology, Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, 1322 BT, 200 Hawkins Drive, Iowa City, IA 52242, United States.
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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Gomes H, Abreu B, Barros L, Veríssimo C. Abnormal Uterine Bleeding in Adolescence: When Menarche Reveals other Surprises. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:789-792. [PMID: 34784636 PMCID: PMC10183936 DOI: 10.1055/s-0041-1736143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Abnormal uterine bleeding is more frequent in adolescence. Although, most commonly, it has a non-structural etiology, it may be due to any cause described. CLINICAL CASE A 12-year-old adolescent, with no relevant personal history, menarche 1 month before, was observed in the emergency department for severe menstrual bleeding with progressive worsening, and hemodynamic repercussion in need of transfusion support. Physiological ovulatory dysfunction associated with possible previously unknown coagulopathy was considered to be the most likely diagnosis and medical treatment was initiated. Without response, the patient was submitted to sedated observation and uterine aspiration, which ultimately led to the diagnosis of a Burkitt Lymphoma. DISCUSSION Although structural causes, and particularly malignancy, whether gynecological or not, are a rare cause of abnormal uterine bleeding in this age group, they must be considered, thus enhancing the fastest and most appropriate treatment.
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Affiliation(s)
- Helena Gomes
- Departament of Gynecology/Obstetrics, Hospital Beatriz Ângelo, Loures, Lisboa, Portugal
| | - Bruna Abreu
- Departament of Gynecology/Obstetrics, Hospital Beatriz Ângelo, Loures, Lisboa, Portugal
| | - Liliana Barros
- Departament of Gynecology/Obstetrics, Hospital Beatriz Ângelo, Loures, Lisboa, Portugal
| | - Carlos Veríssimo
- Departament of Gynecology/Obstetrics, Hospital Beatriz Ângelo, Loures, Lisboa, Portugal
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Srivaths L, Kouides PA. Low von Willebrand Factor in Children and Adolescents: A Review. JAMA Pediatr 2021; 175:1060-1067. [PMID: 34338716 DOI: 10.1001/jamapediatrics.2021.2186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Recent studies have documented increased bleeding symptoms and related complications in patients with low von Willebrand factor (VWF), highlighting the clinical significance of this entity. Because children and adolescents with VWF deficiencies often present to primary care physicians with bleeding symptoms, physicians need to be aware of this condition for early detection. OBSERVATIONS Studies have found that children and adolescents with low VWF (VWF levels of 30-50 IU/dL) can present with clinically significant bleeding, including mucosal, menstrual, postsurgical, and posttraumatic bleeding, leading to complications such as anemia, iron deficiency, transfusion, hospitalization, and poor quality of life. Detecting and promptly managing low VWF in children and adolescents with bleeding are essential because failure to do so can lead to significant morbidity in adulthood, especially among female patients, including continued heavy menstrual bleeding; postpartum hemorrhage; related gynecologic complications, such as hemorrhagic ovarian cysts; and surgical interventions for heavy menstrual bleeding, including hysterectomy. This narrative review summarizes the observations of several studies that have shed light on the pathophysiologic mechanisms of low VWF and bleeding in these patients and the available diagnostic modalities and treatment options. CONCLUSIONS AND RELEVANCE Studies in children and adolescents have provided important insights into the clinical phenotype, complications, pathophysiologic mechanisms, evaluation, and management of low VWF, now recognized as an important clinicopathologic entity, as presented in this review. As gatekeepers, primary care physicians play an important role in guiding patients with this recently recognized clinicopathologic entity toward appropriate specialty care and providing continued comanagement to prevent future complications as the patients enter adulthood.
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Affiliation(s)
- Lakshmi Srivaths
- Gulf States Hemophilia & Thrombophilia Center, Department of Pediatrics, McGovern School of Medicine, The University of Texas Health Science Center at Houston, Houston
| | - Peter A Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, New York
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Options for Prevention and Management of Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment: ACOG Committee Opinion, Number 817. Obstet Gynecol 2021; 137:e7-e15. [PMID: 33399429 DOI: 10.1097/aog.0000000000004209] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
ABSTRACT Obstetrician-gynecologists frequently are consulted either before the initiation of cancer treatment to request menstrual suppression or during an episode of severe heavy bleeding to stop bleeding emergently. Adolescents presenting emergently with severe uterine bleeding usually require only medical management; surgical management rarely is required. Surgical management should be considered for patients who are not clinically stable, or for those whose conditions are not suitable for medical management or have failed to respond appropriately to medical management. When used continuously, combined hormonal contraceptives are effective for producing amenorrhea, although complete amenorrhea cannot be guaranteed. The risk of venous thromboembolism in patients with cancer is compounded by multiple factors, including presence of metastatic or fast-growing, biologically aggressive cancers; hematologic cancers; treatment-related factors such as surgery or central venous catheters; and the number and type of comorbid conditions. Although as a group, patients undergoing cancer treatment are at elevated risk of venous thromboembolism compared with the general population, this risk may be extremely elevated for certain patients and existing guidance on risk stratification should be consulted. The decision to use estrogen in patients with cancer should be tailored to the individual patient after collaborative consideration of the risk-benefit ratio with the patient and the health care team; the patient should be closely monitored for known adverse effects such as liver toxicity and venous thromboembolism.
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Jain S, Zhang S, Acosta M, Malone K, Kouides P, Zia A. Prospective evaluation of ISTH-BAT as a predictor of bleeding disorder in adolescents presenting with heavy menstrual bleeding in a multidisciplinary hematology clinic. J Thromb Haemost 2020; 18:2542-2550. [PMID: 32654321 DOI: 10.1111/jth.14997] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/30/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) can be the first manifestation of an undiagnosed bleeding disorder (BD). Identifying a BD can be challenging in the adolescent age group. The utility of bleeding assessment tools (BAT) remains elusive in this population. AIM We evaluated the ability of the International Society on Thrombosis and Haemostasis-BAT (ISTH-BAT) in predicting a BD in adolescents referred for HMB to a multidisciplinary hematology clinic. METHODS Two hundred adolescents with HMB underwent a standardized evaluation for BD. The clinical characteristics, laboratory data, and bleeding scores (BS) assessed using ISTH-BAT were prospectively collected. Comparisons were made between patients based on the diagnosis of BD receiver operating characteristic (ROC) curve analyses of ISTH-BAT were performed to assess its value for predicting BD. RESULTS Overall, 33% (n = 67) of adolescents were diagnosed with a BD. The mean ISTH-BAT BS was higher in BD as compared to those without (4.1 versus 3.1, P < .0001), but the mean menorrhagia-specific scores did not differ (2.9 in both groups). The ISTH-BAT demonstrated a modest discriminative ability as a screening tool to identify BD in girls with HMB with an area under the curve (AUC) of 0.71. The ROC analysis demonstrated that with increasing BS, the sensitivity decreased, but the specificity increased. At BS = 3, sensitivity was 88%, specificity 31%, and accuracy 50%; at BS = 5, sensitivity was 37%, specificity 94%, and accuracy was 75%. There was no change thereafter. CONCLUSION In adolescents with HMB, an ISTH-BAT BS of >4 instead of the established cut-off of >2 in children is highly specific in predicting a BD.
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Affiliation(s)
- Shilpa Jain
- Division of Pediatric Hematology-Oncology, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
- Western New York BloodCare, Buffalo, NY, USA
| | - Song Zhang
- Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kendra Malone
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, NY, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department(s) of Pediatrics, Children's Medical Center, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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HMB in the Adolescent: A Review of the Modern Approach to Diagnosis and Management. Clin Obstet Gynecol 2020; 63:553-560. [PMID: 32732502 DOI: 10.1097/grf.0000000000000523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Heavy menstrual bleeding in the adolescent is a cause for concern whether occurring acutely or chronically. There are a number of important considerations during the initial presentation that will help guide the practitioner during workup, which ultimately guides management strategies. The cornerstone of management in the adolescent is that of medical therapy (hormonal and nonhormonal), with avoidance of invasive and irreversible measures, as maintenance of fertility is paramount. Ultimately, the majority of adolescents can be successfully managed in the acute setting and transitioned to maintenance therapy for long-term control of heavy menses. Here, we will review the modern approach to this condition as well as tips and tricks for the practitioner.
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Srivaths L, Minard CG, O'Brien SH, Wheeler AP, Mullins E, Sharma M, Sidonio R, Jain S, Zia A, Ragni MV, Kulkarni R, Dietrich JE, Kouides PA. The spectrum and severity of bleeding in adolescents with low von Willebrand factor-associated heavy menstrual bleeding. Blood Adv 2020; 4:3209-3216. [PMID: 32663297 PMCID: PMC7362347 DOI: 10.1182/bloodadvances.2020002081] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/29/2020] [Indexed: 01/31/2023] Open
Abstract
Low von Willebrand factor (VWF) in adults is associated with significant bleeding, most notably heavy menstrual bleeding (HMB) and postpartum hemorrhage, although this has not been characterized in adolescents. The objectives of this analysis of a multicenter single arm observational cohort study in adolescents with low VWF-associated HMB were to describe the bleeding phenotype, HMB severity, and related complications. Eligibility criteria included postmenarchal females <21 years of age with HMB (Pictorial Blood Assessment Chart [PBAC] score >100) and low VWF (2 values of VWF activity ≥30 and ≤50 IU/dL). Patients diagnosed with other bleeding disorders were ineligible. Clinical phenotype data, including PBAC and Bleeding Assessment Tool (BAT) scores, laboratory data, and HMB management/outcome details, were extracted. Patient demographics and clinical characteristics were summarized as medians with minimum/maximum values or frequencies with percentages. Groups were compared using a Wilcoxon rank-sum test or Fisher's exact test. A total of 113 patients met inclusion criteria, and 2 were excluded. Ninety four percent had a significant bleeding phenotype (BAT score >2), with predominantly mucocutaneous bleeding (32%-44%), postprocedural/surgical bleeding (15%), and severe HMB (BAT HMB domain score ≥2; 90%). Bleeding complications included iron deficiency (60%), anemia (21%), transfusion (12%), and hospitalization (10%). Desmopressin challenge response in subjects tested was good and sustained. Several (48%) required combined therapy for HMB (hormonal/hemostatic), and one third did not show improvement despite therapy. Our results suggest that adolescent females with low VWF have a significant bleeding phenotype and resultant complications warranting a focus on prompt diagnosis, appropriate therapy, and prevention of complications.
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Affiliation(s)
- Lakshmi Srivaths
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Charles G Minard
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH
| | - Allison P Wheeler
- Department of Pediatrics, Vanderbilt University Medical Center, Vanderbilt, TN
| | - Eric Mullins
- Division of Hematology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital, Cincinnati, OH
| | - Mukta Sharma
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | - Shilpa Jain
- Department of Pediatrics, University of Buffalo, Buffalo, NY
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas, Southwestern, Dallas, TX
| | - Margaret V Ragni
- Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Roshni Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI
| | - Jennifer E Dietrich
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; and
| | - Peter A Kouides
- Department of Medicine, University of Rochester, Rochester, NY
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Bellis EK, Li AD, Jayasinghe YL, Girling JE, Grover SR, Peate M, Marino JL. Exploring the Unmet Needs of Parents of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study. J Pediatr Adolesc Gynecol 2020; 33:271-277. [PMID: 31874316 DOI: 10.1016/j.jpag.2019.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE To provide insight into the unmet needs of parents of adolescents with heavy menstrual bleeding or dysmenorrhea, in the context of their daughters' menstrual concerns. DESIGN Qualitative interview study using semi-structured interviews. SETTING Gynecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia. PARTICIPANTS Parents of adolescent girls with heavy menstrual bleeding or dysmenorrhea recruited from an adolescent gynecology clinic between May and August 2018. INTERVENTIONS In depth, semi-structured interviews with 24 parents whose daughters had heavy menstrual bleeding or dysmenorrhea. Data were analyzed using a grounded theory approach. MAIN OUTCOME MEASURES Themes derived from interview transcripts about the supportive care needs of parents. RESULTS Thirteen themes emerged in the interviews across 4 areas of need: (1) experiences with healthcare, (2) informational needs, (3) support and acceptance, and (4) financial impacts. Across the interviews, parents identified a need for greater awareness and education among parents and daughters, health professionals, and the broader community. CONCLUSION This research confirmed that parents play a significant role in daughters' menstrual health care and have a series of unmet needs. Strategies and interventions specifically targeting these parents may be warranted.
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Affiliation(s)
- Emily K Bellis
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Anna D Li
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Yasmin L Jayasinghe
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, VIC, Australia; Department of Paediatric and Adolescent Gynaecology, The Royal Children's Hospital, VIC, Australia
| | - Jane E Girling
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, VIC, Australia; Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Sonia R Grover
- Department of Paediatric and Adolescent Gynaecology, The Royal Children's Hospital, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Michelle Peate
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, VIC, Australia.
| | - Jennifer L Marino
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, VIC, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Australia
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Adolescents Presenting to the Emergency Department with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2020; 33:139-143. [PMID: 31765796 DOI: 10.1016/j.jpag.2019.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To describe the adolescent population that seeks care in the emergency department (ED) for heavy menstrual bleeding (HMB), and to compare those who are discharged to those who are admitted to the hospital. DESIGN Retrospective study. SETTING Emergency department and inpatient unit at a national tertiary care hospital from 2006-2018. PARTICIPANTS Adolescents 11-19 years old with ICD-9 and ICD-10 codes for HMB. INTERVENTIONS Chart abstraction for demographic data, symptoms, laboratory tests, outcomes, and treatments. MAIN OUTCOME MEASURE Adolescents who were admitted were compared to girls who were treated as outpatients. RESULTS There were 258 adolescents who sought care for HMB in the ED during the study period. A total of 44 patients (17%) were admitted to the hospital, whereas 214 (83%) were discharged. The average age of those admitted was 15 years, compared to 17 years for those discharged (P < .001). In the admitted group, the mean initial hemoglobin (Hgb) was 6.3 g/dL compared to 12.0 g/dL in the discharged group (P < .0001). Only 23% of the discharged patients were released with medications; the remainder did not receive treatment. Anovulation was the etiology of HMB in the majority (56%) of both inpatients and outpatients. Of the 44 adolescents admitted to the hospital for HMB, 12 (27%) had a bleeding disorder (BD) and 32 (73%) did not. CONCLUSION The majority of adolescents who presented to the emergency department for HMB were not anemic and did not receive any treatment. Of those admitted, almost one-third had an underlying BD, which is higher than previously reported.
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Yaşa C, Güngör Uğurlucan F. Approach to Abnormal Uterine Bleeding in Adolescents. J Clin Res Pediatr Endocrinol 2020; 12:1-6. [PMID: 32041387 PMCID: PMC7053441 DOI: 10.4274/jcrpe.galenos.2019.2019.s0200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 12/11/2019] [Indexed: 01/15/2023] Open
Abstract
This article reviews the current understanding and management of abnormal uterine bleeding (AUB) in adolescents. It is hoped that this review will provide readers with an approach to the evaluation and treatment of mild to severe uterine bleeding. AUB is a common problem which has significantly adverse effects on an affected adolescent’s quality of life. The most common underlying condition in AUB in adolescence is anovulation. During the evaluation, pregnancy, trauma and sexually transmitted diseases must be ruled out, regardless of history. It should be kept in mind that AUB during this period may be the first sign of underlying bleeding disorders. Although observation is sufficient in the mild form of AUB, at the other end of the spectrum life-threatening bleeding may necessitate the use of high doses of combined oral contraceptives, intravenous estrogen and/or interventional procedures.
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Affiliation(s)
- Cenk Yaşa
- İstanbul University, İstanbul Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Funda Güngör Uğurlucan
- İstanbul University, İstanbul Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
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Borzutzky C, Jaffray J. Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents. JAMA Pediatr 2020; 174:186-194. [PMID: 31886837 DOI: 10.1001/jamapediatrics.2019.5040] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Heavy menstrual bleeding is a common cause of anemia and reduced quality of life in adolescents. There is a higher prevalence of bleeding disorders in girls with heavy menstrual bleeding than in the general population. Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care. OBSERVATIONS The most common cause of heavy menstrual bleeding in adolescents is ovulatory dysfunction, followed by coagulopathies. The most common inherited bleeding disorder is von Willebrand disease, and its incidence in adolescents with heavy menstrual bleeding is high. Distinguishing the etiology of heavy menstrual bleeding will guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. Among hormonal agents, the 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders. CONCLUSIONS AND RELEVANCE Anemia, need for transfusion of blood products, and hospitalization may be avoided with prompt recognition, diagnosis, and treatment of heavy menstrual bleeding, especially when in the setting of bleeding disorders. Safe and effective treatment methods are available and can greatly improve quality of life for affected adolescents. A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal.
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Affiliation(s)
- Claudia Borzutzky
- Keck School of Medicine of University of Southern California, Los Angeles.,Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Julie Jaffray
- Keck School of Medicine of University of Southern California, Los Angeles.,Children's Center for Cancer and Blood Diseases, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
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Papapanagiotou IK, Charamanta M, Roidi S, Al-Achmar NS, Soldatou A, Michala L. The Use of Norethisterone for the Treatment of Severe Uterine Bleeding in Adolescents: An Audit of Our Experience. J Pediatr Adolesc Gynecol 2019; 32:596-599. [PMID: 31520717 DOI: 10.1016/j.jpag.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/27/2019] [Accepted: 09/01/2019] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE The purpose of this prospective study was to assess the effectiveness of norethisterone (NET) in the management of abnormal uterine bleeding (AUB) in adolescents in a tertiary care center. DESIGN This was a prospective audit focused on administering high doses of NET in female adolescents with complaints of AUB. SETTING We included female adolescents who presented to our Emergency Gynecological Department or Adolescent Gynecological Outpatient Department from October 2016 to January 2019. PARTICIPANTS The study included 29 female adolescents aged 11-17 (mean, 13.14) years. INTERVENTIONS Patients were administered a daily dose of 10-30 mg, depending on the severity of the condition, bleeding duration, and patient weight. MAIN OUTCOME MEASURES Cessation of vaginal bleeding. RESULTS Mean age at menarche of our patient sample was 11.4 years (range, 10.7-14 years). AUB presented at a mean time of 24.6 months after menarche (range, 0-79 months). Blood transfusion was deemed necessary in 9 patients. Bleeding stopped at a mean of 46.1 (range, 8-120) hours after onset of treatment with NET. No serious adverse events were reported with NET administration, with only 3 cases of minor side effects. CONCLUSION The use of NET is an effective and reliable treatment option among adolescents for whom control of AUB is desired in the acute setting.
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Affiliation(s)
- Ioannis K Papapanagiotou
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, "Alexandra" General Hospital, Athens, Greece
| | - Maria Charamanta
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, "Alexandra" General Hospital, Athens, Greece
| | - Stella Roidi
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, "Alexandra" General Hospital, Athens, Greece
| | - Nikolaos Samer Al-Achmar
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, "Alexandra" General Hospital, Athens, Greece
| | - Alexandra Soldatou
- Second Department of Pediatrics, National and Kapodistrian University of Athens, Panagiotis and Aglaia Kyriakou Hospital, Athens, Greece
| | - Lina Michala
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, "Alexandra" General Hospital, Athens, Greece.
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O'Brien SH. Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:390-398. [PMID: 30504337 PMCID: PMC6246024 DOI: 10.1182/asheducation-2018.1.390] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting >7 days, menstrual flow which soaks >5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH; and
- Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, OH
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Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist. Blood 2018; 132:2134-2142. [DOI: 10.1182/blood-2018-05-848739] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
Abstract
Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting >7 days, menstrual flow which soaks >5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.
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