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Misunas C, Hindin MJ, Phillips-Howard PA, Sommer M. The Association Between Hormonal Contraceptive Use and Anemia Among Adolescent Girls and Young Women: An Analysis of Data From 51 Low- and Middle-Income Countries. J Adolesc Health 2024; 74:563-572. [PMID: 37978956 PMCID: PMC11239219 DOI: 10.1016/j.jadohealth.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This study explores whether adolescent girls and young women aged 15-24 who use hormonal methods of contraception are more or less likely to be anemic than their peers. We further examine whether the association between anemia and hormonal contraception varies based on the severity of anemia or the duration of method use. METHODS We conducted secondary analysis of data available for 51 low- and middle-income countries from the Demographic and Health Surveys. For each country, we used logistic regression models to explore the odds of being anemic (mildly, moderately, or severely) for those using hormonal methods of contraception. We also explored the odds of being moderately or severely anemic based on hormonal method use. Drawing on country-level effect estimates, we conducted meta-regression analyses to produce overall estimates of the association between anemia and hormonal contraception. RESULTS Overall, adolescent girls and young women using hormonal methods had lower odds of being mildly, moderately, or severely anemic (adjusted odds ratio 0.68; p < .001) and lower odds of being moderately or severely anemic (adjusted odds ratio 0.57; p < .001) compared to those not using any contraception. Both short- and long-term users of hormonal methods had lower odds of being anemic and lower odds of being moderately or severely anemic compared to those not using hormonal methods. DISCUSSION This study furthers our understanding of the association between anemia and use of hormonal contraception among adolescent girls and young women. More research is needed to assess causality and whether hormonal methods mediate the effects of heavy menstrual bleeding or other risk factors of anemia.
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Affiliation(s)
- Christina Misunas
- Department of Demography, University of California, Berkeley, Berkeley, California.
| | - Michelle J Hindin
- Global Health and Population Research Department, FHI 360, Durham, North Carolina
| | | | - Marni Sommer
- Department of Sociomedical Sciences, Columbia University, New York, New York
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Rosen MW, Compton SD, Weyand AC, Quint EH. The Utility of Pelvic Ultrasounds in Adolescents Presenting to the Emergency Department with Abnormal Uterine Bleeding. J Pediatr Adolesc Gynecol 2023; 36:455-458. [PMID: 37182811 DOI: 10.1016/j.jpag.2023.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
STUDY OBJECTIVE To analyze what factors influence a provider's decision to order a pelvic ultrasound (PUS) in the emergency department (ED) for adolescents with abnormal uterine bleeding (AUB), to determine if endometrial stripe (EMS) measurements are used in treatment decisions, and to evaluate if treatment outcomes differ based on EMS thicknesses. METHODS Retrospective chart review of patients aged 11-19 presenting to the ED with AUB from 2006 to 2018. Those receiving a PUS were divided into three EMS groups: ≤5 mm, 6-9 mm, and ≥10 mm. Outcomes were evaluated in admitted patients by progress notes indicating resolution of bleeding. Cross-tab, χ2, and logistic and linear regression analysis were performed. RESULTS Of 258 adolescents meeting study criteria, 113 (43.8%) had a PUS. None had an abnormality. A PUS was more likely to be performed in patients with lower hemoglobin values (P < .003). Provider decision to order a PUS did not differ by age or bleeding duration (P > .1). Among those with a PUS, 67 (59%) received hormonal therapy (pill, progestin-only, IV estrogen). There were no significant differences in treatment choices based on EMS (P < .061) or, among the 44 admitted patients (17%), in the time it took bleeding to stop after initiating treatment (pill: P = .227, progestin-only: P = .211, IV estrogen: P = .229). CONCLUSION In adolescents with AUB in the ED, performing a PUS was more common in those with low hemoglobin. EMS thickness did not appear to affect treatment decisions or inpatient outcomes. Larger studies are needed to confirm the current findings and determine if PUS is needed in the evaluation of AUB.
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Affiliation(s)
- Monica W Rosen
- Department of Obstetrics & Gynecology, Michigan Medicine, Ann Arbor, Michigan.
| | - Sarah D Compton
- Department of Obstetrics & Gynecology, Michigan Medicine, Ann Arbor, Michigan
| | - Angela C Weyand
- Department of Pediatric Hematology, Michigan Medicine, Ann Arbor, Michigan
| | - Elisabeth H Quint
- Department of Obstetrics & Gynecology, Michigan Medicine, Ann Arbor, Michigan
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Kızılcan Çetin S, Aycan Z, Özsu E, Şıklar Z, Ceran A, Erişen Karaca S, Şenyazar G, Berberoğlu M. Evaluation of Abnormal Uterine Bleeding in Adolescents: Single Center Experience. J Clin Res Pediatr Endocrinol 2023; 15:230-237. [PMID: 36794870 PMCID: PMC10448548 DOI: 10.4274/jcrpe.galenos.2023.2022-10-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/04/2023] [Indexed: 02/17/2023] Open
Abstract
Objective Abnormal uterine bleeding (AUB) is the most common gynecologic complaint in adolescent girls. The aim of this study was to identify the diagnostic and management differences between those with/without heavy menstrual bleeding. Methods Retrospective data was collected from adolescents aged 10-19 years, diagnosed with AUB. Adolescents with known bleeding disorders at admission were excluded. All girls were classified according to the degree of anemia; group 1 had heavy bleeding [hemoglobin (Hb) <10 g/dL] and group 2 had moderate or mild bleeding (Hb >10 g/dL). Admission and follow-up characteristics were compared between the two groups. Results The cohort consisted of 79 girls with a mean age of 14.3±1.8 years and mean age of menarche of 11.9±1.4 years, with 85% experiencing menstrual irregularity in the two years after menarche, rising to 95.3% in group 1 (p<0.01). Anovulation was evident in 80% of the cohort. Of these 79 girls, 13 (16.5%) had polycystic ovary syndrome and two (2.5%) had structural anomalies (uterus didelphys). Three girls (group 1, n=2) had previously undiagnosed clotting factor VII deficiency; no other clotting deficiencies were diagnosed. Nineteen of 34 (56%) with personal (n=2)/family history of thrombosis had MTHFR mutation. None had venous thromboembolism during follow-up of >6 months. Conclusion The majority of AUB (85%) occurred in the first two years after menarche. A small proportion (3.8%) had undiagnosed clotting factor deficiency. The frequency of MTHFR mutation was 50% in girls with history of thrombosis; however this did not increase the risk of bleeding/thrombosis and so routine evaluation does not appear to be justified.
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Affiliation(s)
- Sirmen Kızılcan Çetin
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zehra Aycan
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
- Ankara University Faculty of Medicine, Department of Adolescent Health, Ankara, Turkey
| | - Elif Özsu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Ayşegül Ceran
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Seda Erişen Karaca
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Gizem Şenyazar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Luiro K, Holopainen E. Heavy Menstrual Bleeding in Adolescent: Normal or a Sign of an Underlying Disease? Semin Reprod Med 2021; 40:23-31. [PMID: 34734398 DOI: 10.1055/s-0041-1739309] [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]
Abstract
Heavy, and often irregular, menstrual bleeding (HMB) is a common gynecologic complaint among adolescents. During the first few post-menarcheal years, anovulatory cycles related to immaturity of the hypothalamic-pituitary-ovarian axis are the most common etiology for abnormal uterine bleeding and should be considered as a part of normal pubertal development rather than a disease. If an already regular menstrual cycle becomes irregular, secondary causes of anovulation should be ruled out. Inherited and acquired bleeding disorders, such as von Willebrand disease, and quantitative and qualitative abnormalities of platelets are relatively common findings in adolescents with HMB from menarche. History of excessive bleeding or a diagnosed bleeding disorder in the family supports this etiology, warranting specialized laboratory testing. First-line treatment of HMB among adolescents is medical management with hormonal therapy or nonhormonal options. Levonorgestrel-releasing intrauterine device is an effective tool also for all adolescents with menstrual needs.
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Affiliation(s)
- Kaisu Luiro
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Elina Holopainen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
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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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Schrager S, Larson M, Carlson J, Ledford K, Ehrenthal DB. Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women. J Womens Health (Larchmt) 2020; 29:937-943. [PMID: 32155101 DOI: 10.1089/jwh.2019.7731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Contraceptives that contain estrogen and/or progestins are used by millions of women around the world to prevent pregnancy. Owing to their unique physiological mechanism of action, many of these medications can also be used to prevent cancer and treat multiple general medical conditions that are common in women. We performed a comprehensive literature search. This article will describe the specific mechanisms of action and summarize the available data documenting how hormonal contraceptives can prevent ovarian and uterine cancer and be used to treat women with a variety of gynecological and nongynecological conditions such as endometriosis, uterine fibroids, heavy menstrual bleeding, polycystic ovary syndrome, acne, and migraines. Contraceptive methods containing estrogen and progestin can be used for a wide variety of medical issues in women.
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Affiliation(s)
- Sarina Schrager
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Magnolia Larson
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jensena Carlson
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kathryn Ledford
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Deborah B Ehrenthal
- Department of Obstetrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Gynecology and Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
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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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Heavy menstrual bleeding among women aged 18-50 years living in Beijing, China: prevalence, risk factors, and impact on daily life. BMC WOMENS HEALTH 2019; 19:27. [PMID: 30717736 PMCID: PMC6360654 DOI: 10.1186/s12905-019-0726-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/25/2019] [Indexed: 01/29/2023]
Abstract
Background Heavy menstrual bleeding (HMB) has been shown to have a profound negative impact on women’s quality of life and lead to increases in health care costs; however, data on HMB among Chinese population is still rather limited. The present study therefore aimed to determine the current prevalence and risk factors of subjectively experienced HMB in a community sample of Chinese reproductive-age women, and to evaluate its effect on daily life. Methods We conducted a questionnaire survey in 2356 women aged 18–50 years living in Beijing, China, from October 2014–July 2015. A multivariate logistic regression model was used to identify risk factors for HMB. Results Overall, 429 women experienced HMB, giving a prevalence of 18.2%. Risk factors associated with HMB included uterine fibroids (adjusted odds ratio [OR] =2.12, 95% confidence interval [CI] = 1.42–3.16, P < 0.001) and multiple abortions (≥3) (adjusted OR = 3.44, 95% CI = 1.82–6.49, P < 0.001). Moreover, women in the younger age groups (≤24 and 25–29 years) showed higher risks for HMB, and those who drink regularly were more likely to report heavy periods compared with never drinkers (adjusted OR = 2.78, 95% CI = 1.20–6.46, P = 0.017). In general, women experiencing HMB felt more practical discomforts and limited life activities while only 81 (18.9%) of them had sought health care for their heavy bleeding. Conclusions HMB was highly prevalent among Chinese women and those reporting heavy periods suffered from greater menstrual interference with daily lives. More information and health education programs are urgently needed to raise awareness of the consequences of HMB, encourage women to seek medical assistance and thus improve their quality of life. Electronic supplementary material The online version of this article (10.1186/s12905-019-0726-1) contains supplementary material, which is available to authorized users.
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Alaqzam TS, Stanley AC, Simpson PM, Flood VH, Menon S. Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2018. [PMID: 29524595 DOI: 10.1016/j.jpag.2018.02.130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We performed a retrospective chart review of adolescents younger than 21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information including demographic characteristics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into 2 categories on the basis of the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared. RESULTS Seventy-three subjects were tested for a bleeding disorder. Of the subjects who completed testing, 34 (46%) were diagnosed with a bleeding disorder. Thirty-nine subjects (54%) had heavy menstrual bleeding because of other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without a bleeding disorder. In a comparison of hormone therapy success, the levonorgestrel intrauterine device (89%, 8 out of 9 subjects) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10 mg/d (83%, 5 out of 6 subjects), and the transdermal patch (80%, 4 out of 5 subjects). All subjects using tranexamic acid as well as hormonal therapy had 100% achievement of menstrual suppression. CONCLUSION A high frequency of bleeding disorders was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. Although combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option.
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Affiliation(s)
- Tasneem S Alaqzam
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Angela C Stanley
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa M Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Veronica H Flood
- Division of Hematology and Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seema Menon
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Powers JM, Stanek JR, Srivaths L, Haamid FW, O'Brien SH. Hematologic Considerations and Management of Adolescent Girls with Heavy Menstrual Bleeding and Anemia in US Children's Hospitals. J Pediatr Adolesc Gynecol 2018; 31:446-450. [PMID: 29940313 DOI: 10.1016/j.jpag.2018.06.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVE To assess the frequency, severity, and inpatient management of girls admitted with heavy menstrual bleeding and iron deficiency anemia at US children's hospitals, with a focus on hematologic considerations. DESIGN Retrospective multicenter cohort study from October 2012 through September 2015. SETTING Children's hospitals submitting data to the Pediatric Health Information System. PARTICIPANTS Female patients, age 8-18 years, admitted with heavy menstrual bleeding and anemia as either a primary or secondary diagnosis. Patients with cancer, immune thrombocytopenic purpura, aplastic anemia, and pregnancy were excluded. INTERVENTIONS AND MAIN OUTCOME MEASURES Hemostatic evaluation; provision of iron therapy. RESULTS We identified 1183 admissions (1134 unique patients). Patients' median (interquartile range) age was 14 (11-17) years. Forty-one percent were Caucasian (n = 480), 31% African American (n = 371), and 26% Hispanic ethnicity (n = 310). Intensive care use occurred in 5% of admissions (n = 56). Hemostatic assessment was inconsistent; 15% (n = 182) had no such evaluation. Two-thirds (n = 797; 67%) involved transfusions, 37% (n = 433) received no inpatient iron therapy, and 17% (n = 197) received no hormonal or antifibrinolytic therapy. Hemostatic evaluation was associated with intensive care use: odds ratio (OR), 4.80 (95% confidence interval [CI], 1.16-19.86; P = .03); emergency department visit: OR, 2.60 (95% CI, 1.86-3.65; P < .01); private insurance: OR, 1.62 (95% CI, 1.12-2.35; P = .01); and younger age: OR, 0.84 (95% CI, 0.77-0.92; P < .01). CONCLUSION Hundreds of girls with heavy menstrual bleeding and anemia are hospitalized at US children's hospitals each year with variable inpatient hematologic evaluation and management. Future guidelines should emphasize early identification of at-risk patients and promote effective implementation strategies to reduce the burden of this preventable complication.
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas.
| | - Joseph R Stanek
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
| | - Lakshmi Srivaths
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | - Fareeda W Haamid
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Sarah H O'Brien
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
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12
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Srivaths LV, Zhang QC, Byams VR, Dietrich JE, James AH, Kouides PA, Kulkarni R. Differences in bleeding phenotype and provider interventions in postmenarchal adolescents when compared to adult women with bleeding disorders and heavy menstrual bleeding. Haemophilia 2017; 24:63-69. [PMID: 28873279 DOI: 10.1111/hae.13330] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Due to lack of patient/health care provider awareness causing delayed diagnosis, the bleeding phenotype and provider interventions in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD) may be different when compared to adults. AIM The aim of this study was to compare/characterize bleeding phenotype and provider interventions in postmenarchal adolescents < 18 years and premenopausal adults ≥ 18 years with HMB and BD. METHODS Patient demographics, BD, and provider interventions/therapy details for HMB were compared between both age groups enrolled in the Centers for Disease Control and Prevention (CDC) Female Universal Data Collection (UDC) surveillance project in United States hemophilia treatment centres. Cross-sectional descriptive analyses including frequency distributions, summary statistics, bivariate and logistic regression analyses were performed. RESULTS Of 269 females (79 adolescents; median age 16 years, interquartile range (IQR) = 2; 190 adults; median age 27 years, IQR = 13) evaluated, BD distribution was similar in both groups. Compared to adolescents, adults more often had family history of bleeding (Adjusted odds ratios [AOR] = 2.6, 1.3-5.6), delay in diagnosis (AOR = 2.5, 1.2-4.9), bleeding with dental procedures (AOR = 2.0, 1.0-4.0), gastrointestinal bleeding (AOR = 4.6, 1.0-21.9), anaemia (AOR = 2.7, 1.4-5.2), utilized desmopressin less often (AOR = 0.4, 0.2-0.8) and underwent gynaecologic procedure/surgery more frequently (AOR = 5.9, 1.3-27.3). CONCLUSION Bleeding phenotypes of adolescents and adults with HMB and BD were different with more frequent bleeding complications, anaemia, gynaecologic procedures/surgeries, less desmopressin use and more delay in diagnosing BD in adults. Longitudinal studies are needed to determine whether improved patient/provider awareness and education will translate to early diagnosis and timely management of BD/HMB in adolescents that may prevent/reduce future haematologic/gynaecologic complications.
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Affiliation(s)
- L V Srivaths
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Q C Zhang
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - V R Byams
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J E Dietrich
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - A H James
- Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - P A Kouides
- Mary M. Gooley Hemophilia Treatment Center, Rochester, NY, USA
| | - R Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI, USA
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13
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Heavy Menstrual Bleeding in Adolescents. J Pediatr Adolesc Gynecol 2017; 30:335-340. [PMID: 28108214 DOI: 10.1016/j.jpag.2017.01.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/14/2016] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
Heavy menstrual bleeding (HMB) is a very common gynecological condition in female adolescents and a frequent presenting complaint of those with bleeding disorders. Recommendations have been established to screen for bleeding disorders in this age group where appropriate. The purpose of this document is to impart clinical recommendations regarding HMB in adolescents. Specifically, in this article we provide a description of the epidemiology, clinical presentation, diagnostic approach, and treatment of HMB in adolescents.
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14
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Cooke AG, McCavit TL, Buchanan GR, Powers JM. Iron Deficiency Anemia in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2017; 30:247-250. [PMID: 27789349 DOI: 10.1016/j.jpag.2016.10.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/09/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To assess the clinical severity and initial treatment of iron deficiency anemia (IDA) in female adolescents with heavy menstrual bleeding (HMB) in our center. DESIGN Retrospective cohort study of electronic medical records via search of administrative records using International Classification of Diseases Ninth Revision codes for IDA or unspecified anemia and disorders of menstruation. SETTING Children's Medical Center in Dallas, Texas. PARTICIPANTS One hundred seven patients with HMB and concomitant IDA (median age, 14.4 years) who presented to the outpatient, emergency department, and/or inpatient settings. RESULTS The median initial hemoglobin concentration for all patients (n = 107) was 7.4 g/dL, and most (74%, n = 79) presented to the emergency department or via inpatient transfer. Symptomatic IDA was treated with blood transfusion in 46 (43%, n = 46). Ferrous sulfate was the most commonly prescribed oral iron therapy. Seven patients received intravenous iron therapy either initially or after oral iron treatment failure. Combined oral contraceptives were commonly prescribed for abnormal uterine bleeding, yet 10% of patients (n = 11) received no hormonal therapy during their initial management. Evaluation for underlying bleeding disorders was inconsistent. CONCLUSION Severe anemia because of IDA and HMB resulting in urgent medical care, including hospitalization and blood transfusion, is a common but underemphasized problem in adolescent girls. In addition to prevention and early diagnosis, meaningful efforts to improve initial management of adolescents with severe HMB and IDA are necessary.
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Affiliation(s)
- Amanda G Cooke
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Timothy L McCavit
- Division of Hematology-Oncology, Department of Pediatrics, Cook Children's Hospital, Fort Worth, Texas
| | - George R Buchanan
- Division of Hematology-Oncology, Department of Pediatrics, UT Southwestern Medical Center and Children's Medical Center, Dallas, Texas
| | - Jacquelyn M Powers
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.
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15
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Rajpurkar M, O'Brien SH, Haamid FW, Cooper DL, Gunawardena S, Chitlur M. Heavy Menstrual Bleeding as a Common Presenting Symptom of Rare Platelet Disorders: Illustrative Case Examples. J Pediatr Adolesc Gynecol 2016; 29:537-541. [PMID: 26876967 DOI: 10.1016/j.jpag.2016.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/01/2016] [Accepted: 02/04/2016] [Indexed: 11/28/2022]
Abstract
Heavy menstrual bleeding (HMB) is a common symptom in patients who present to the obstetrician-gynecologist or adolescent medicine specialist and might result from an underlying inherited bleeding disorder. Whereas relatively common bleeding disorders such as von Willebrand disease are often included in standard laboratory assessments, rarer platelet function disorders can be challenging to diagnose. Additionally, HMB can be a particularly difficult symptom to manage in adolescents with platelet function disorders, and it is associated with decreased quality of life. We review the diagnostic and management issues of patients with platelet function disorders through the presentation of 2 patient case reports, with a focus on a diagnosis of Glanzmann thrombasthenia, an inherited qualitative disorder that affects platelet function. Whereas the first patient presented to the emergency department before the diagnosis of a bleeding disorder and required a hematologic referral and extensive laboratory assessments, the second patient had been diagnosed with Glanzmann thrombasthenia as a child but experienced severe management challenges at the onset of menarche. In both patients, collaboration between the obstetrician-gynecologist or adolescent medicine specialist and the hematologist was critical for achieving acute management of the bleeding symptoms and for ensuring optimal long-term disease management. Together, these cases highlight the importance of properly identifying females with HMB who might have an undiagnosed bleeding disorder and of consulting with a hematologist to determine an appropriate management plan throughout all life stages.
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Affiliation(s)
- Madhvi Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Wayne State University and Children's Hospital of Michigan, Detroit, Michigan.
| | | | | | - David L Cooper
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc, Plainsboro, New Jersey
| | - Sriya Gunawardena
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc, Plainsboro, New Jersey
| | - Meera Chitlur
- Carman and Ann Adams Department of Pediatrics, Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
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16
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Dietrich JE, Srivaths L. Navigating Hormones and Gynecologic Concerns among Female Adolescents in the Settings of Thrombophilia and Anticoagulation. J Pediatr Adolesc Gynecol 2015; 28:549-53. [PMID: 26820016 DOI: 10.1016/j.jpag.2015.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In the setting of an inherited or acquired thrombophilia, managing a gynecologic concern can be challenging. Nonetheless, careful consideration of the history along with a team approach to management, in which hematologists and gynecologists work together is critical. Thombophilias are important to understand, because certain types pose more risk than others. In addition, it is important to balance baseline factors, which might affect decisions regarding the best way to manage a concurrent gynecologic condition. Relative risks for thrombosis have been well studied for a variety of inherited and acquired conditions. Because of these risks, organizations such as the Centers for Disease Control and Prevention, World Health Organization, and American College of Obstetricians and Gynecologists have compiled clinical guidance recommendations to aid providers when hormonal management might be necessary (ie, to treat conditions such as delayed puberty, ovarian cysts, heavy menstrual bleeding, contraception). It is important to use these resources because there are limited prospective studies on this specific population who present with concurrent gynecologic conditions.
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17
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Abstract
Menstrual suppression--the use of hormones to delay or eliminate menses--is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents.
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18
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Wood PL, Bauman D. Gynaecological issues affecting the obese adolescent. Best Pract Res Clin Obstet Gynaecol 2015; 29:453-65. [DOI: 10.1016/j.bpobgyn.2014.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 10/30/2014] [Indexed: 12/24/2022]
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19
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What to do when she's bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr 2014; 26:413-9. [PMID: 25007322 DOI: 10.1097/mop.0000000000000121] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the current understanding and management of abnormal uterine bleeding (AUB) in adolescents. The readers will learn a practical approach to the evaluation and treatment of mild-to-severe uterine bleeding. RECENT FINDINGS In 2011, a new classification system was proposed to standardize the terminology used to describe AUB. This system is based on the pattern and etiology of bleeding and has been adopted by other organizations. The term dysfunctional uterine bleeding has been replaced by AUB. The negative effect of AUB on adolescents' quality of life is now well established. The levonorgestrel-releasing intrauterine system is considered a first-line treatment for heavy menstrual bleeding and should be considered, especially in those adolescents who may also need contraception. SUMMARY AUB is a common adolescent complaint that can vary from mild to life-threatening if not recognized and treated promptly. This article reviews the appropriate assessment and management of AUB and proposes a practical algorithm that can be used in an office or hospital setting.
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20
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Nelson AL. Progestin-only treatments for acute and chronic heavy menstrual bleeding. Expert Rev Endocrinol Metab 2013; 8:307-309. [PMID: 30736142 DOI: 10.1586/17446651.2013.811870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Anita L Nelson
- a David Geffen School of Medicine at UCLA, Harbor UCLA Medical Center, 1000 W. Carson Street, Torrance, CA 90502, USA.
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