What to do when she's bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents

Health-related quality of life and menstrual problems in adolescents

AIM

To evaluate whether the health-related quality-of-life (HRQoL) scores would be different for adolescents with menstrual problems as compared to those with normal menstruation after taking into account clinical, socio-demographic and life-style factors.

METHODS

The Paediatric Quality of Life Inventory 4.0 scale was used to assess HRQoL in 126 schoolgirls of 16 ± 0.4 years old. The adolescents completed semi-structured questionnaires containing information on social and demographic characteristics, life-style features and menstrual questionnaires that included the following: age of menstruation, menstrual cycle length, duration of production, the number of pads used per day, menstrual pain and drug administration to relieve dysmenorrhea. The menstrual problems were classified into three main groups: dysmenorrhoea, oligomenorrhoea, and heavy menstrual bleeding. Anthropometric measurements were performed by a physician. Medical history was obtained from school medical charts.

RESULTS

Ninety-seven (77%) girls had menstrual problems. Dysmenorrhoea (n = 92, 73%) was the most frequent of these, followed by oligomenorrhoea (n = 13, 10.3%) and heavy menstrual bleeding (n = 6, 4.8%). Thirteen (10.3%) girls had combined disorders. A multivariate analysis adjusted for life-style factors found an independent association of any menstrual problems, oligomenorrhoea and dysmenorrhoea with low HRQoL scores in the emotional functioning domain. For adolescents with oligomenorrhoea, an association with low total scale scores was also shown but it did not reach statistical significance.

CONCLUSION

The prevalence of menstrual problems is high among schoolgirls. Medical professionals working with adolescents should know that girls with menstrual problems are highly likely to have a poor quality of life, especially those with oligomenorrhoea.

Abnormal Uterine Bleeding in Adolescence: When Menarche Reveals other Surprises

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.

Comparison between Different Diagnostic Strategies in Low-Risk Reproductive Age and Pre-Menopausal Women Presenting Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common symptom in the female population, with an estimated prevalence of 10 to 30% in fertile age and up to 90% in perimenopausal women. In most cases, AUB is due to a benign cause. However, it can also be a symptom of atypical endometrial hyperplasia or endometrial cancer, a more common disease during menopause which can also affect women in their reproductive age. Considering the high prevalence of this symptom an appropriate diagnostic algorithm is needed. Concerns about the risks, pain, and stress associated with an endometrial biopsy and its impact on the healthcare system make the choice of AUB diagnostic strategy extremely relevant. Even if the scientific community agrees on the definition of AUB, International Guidelines show some differences in the management of women of reproductive age with AUB, especially regarding the age cut-off as an independent indication for endometrial biopsy. This study compared different diagnostic strategies to identify a diagnostic pathway with high sensitivity and specificity but low impact on the health system's resources. The analysis was based on three diagnostic algorithms defined as part of the guidelines of leading scientific societies. Women of reproductive age with AUB (n = 625) and without risk of endometrial cancer were included in the study. Results showed that the best criterion to investigate AUB in women at low risk of endometrial cancer is not age cut-off but the presence or absence of focal endometrial pathology at the ultrasound and the response to the progestin therapy. This approach makes it possible to perform fewer outpatient hysteroscopic biopsies without excluding positive cases from the examination.

Approach to Abnormal Uterine Bleeding in Adolescents

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.

Improving the Evaluation and Management of Abnormal Uterine Bleeding in Female Adolescents Presenting for Emergency Care

STUDY OBJECTIVE

We sought to improve emergency care for adolescents with abnormal uterine bleeding (AUB) by developing a clinical effectiveness guideline (CEG) and assessing its effect on quality of care.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

A stakeholder engagement group designed a CEG algorithm for emergency AUB management. Pediatric residents received CEG training and their knowledge and attitudes were assessed using pre- and post intervention surveys. International Classification of Diseases ninth and 10th revision codes identified electronic health record data for patients who presented to the pediatric emergency department for AUB 6 months before and after CEG implementation. A weighted, 20-point scoring system consisting of prioritized aspects of history, laboratory studies, and management was developed to quantify the quality of care provided.

MAIN OUTCOME MEASURES

Descriptive statistics, χ² test, Wilcoxon rank sum test, and a run chart were used for analysis.

RESULTS

Pediatric residents reported higher confidence and knowledge scores post CEG implementation. Of the 91 patients identified, 62 met inclusion criteria. Median score was 14 ± 7 before CEG implementation and 15.5 ± 6 after. The Wilcoxon rank sum test showed a difference in AUB evaluation and management scores (P = .09) after implementation of the CEG. Run chart data showed no shifts or trends (overall median score, 14 points). Pre- and post implementation, points were deducted most frequently for not assessing personal/family clotting disorder history. The largest improvements in care were with appropriate medication dosing and disposition.

CONCLUSION

We designed a CEG and educational intervention for AUB management in a pediatric emergency department. These findings suggest our CEG might be an effective tool to improve emergency AUB care for adolescents and could increase trainees' confidence in managing this condition, although additional cycles are needed.

Abnormal Uterine Bleeding in Adolescents

Abnormal uterine bleeding (AUB) is the most common gynecologic complaint of adolescents admitted to hospital. Heavy menstrual bleeding (HMB) is the most frequent clinical presentation of AUB. Anovulatory cycles, owing to immature hypothalamic-pituitary-ovarian axis, is the leading etiology of HMB and there is an accompanying bleeding disorder in almost 20% of patients with HMB. Additionally, endocrine disorders such as hypothyroidism, hyperprolactinemia and polycystic ovary syndrome are possible causes of AUB. Exclusion of bleeding disorders, especially of von Willebrand disease is important for diagnosis and treatment of HMB, particularly in cases with AUB, which has been present since menarche. Management of HMB is based on the underlying etiology and severity of the bleeding. After other causes are excluded, anovulatory heavy bleeding can be treated successfully with combined oral contraceptives and iron supplementation either as an outpatient or in hospital depending on the clinical findings and level of anemia. The epidemiology, clinical presentation, diagnostic approach and treatment of HMB is discussed and our clinical experience in this field is presented in this review.

Addressing sexual and reproductive health in adolescents and young adults with intellectual and developmental disabilities

PURPOSE OF REVIEW

This review provides support for promoting the sexual health of adolescents and young adults with developmental disabilities, and particularly those with intellectual disabilities. It offers guidance for pediatricians on incorporating counseling on sexuality and reproductive healthcare, socially appropriate behavior, and sexual abuse prevention for adolescents and young adults with developmental disabilities into healthcare visits. Additionally, it provides resources for developmentally appropriate sexuality education in the home and community to allow access to the comprehensive sexual and reproductive healthcare patients deserve.

RECENT FINDINGS

Adolescents and young adults with developmental disabilities often do not receive developmentally appropriate sexual health education, and this is associated with poor sexual health outcomes and increased rates of sexual abuse in this population.

SUMMARY

Pediatricians should discuss sexual health with all patients, including adolescents and young adults with developmental disabilities. They are well suited to provide sexual health education and inform families about appropriate sexual health resources.

Heavy Menstrual Bleeding in Adolescents

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.

Important considerations in adolescent health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding

PURPOSE OF REVIEW

The present article addresses recent research related to three key facets of adolescent preventive care and health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding.

RECENT FINDINGS

Recent studies suggest that long-acting reversible contraception use results in significantly lower rates of unintended pregnancies, and is well tolerated by nulliparous adolescent females. Additionally, a strong recommendation from a pediatric primary care provider is extremely effective in ensuring human papillomavirus vaccination prior to sexual debut. Finally, heavy menstrual bleeding is often under-recognized in adolescents, and evaluation and treatment of these patients are variable.

SUMMARY

Based on the recent literature findings, the pediatric primary care provider should be encouraged to, first, recommend long-acting reversible contraception for prevention of unintended pregnancy in adolescent patients; second, strongly endorse vaccination to protect against human papillomavirus in all patients prior to sexual debut; and, third, screen adolescent females for signs and symptoms of heavy menstrual bleeding.

PALM-COEIN Nomenclature for Abnormal Uterine Bleeding

Approximately 30% of women will experience abnormal uterine bleeding (AUB) during their life time. Previous terms defining AUB have been confusing and imprecisely applied. As a consequence, both clinical management and research on this common problem have been negatively impacted. In 2011, the International Federation of Gynecology and Obstetrics (FIGO) Menstrual Disorders Group (FMDG) published PALM-COEIN, a new classification system for abnormal bleeding in the reproductive years. Terms such as menorrhagia, menometrorrhagia, metrorrhagia, dysfunctional uterine bleeding, polymenorrhea, oligomenorrhea, and uterine hemorrhage are no longer recommended. The PALM-COEIN system was developed to standardize nomenclature to describe the etiology and severity of AUB. A brief description of the PALM-COEIN nomenclature is presented as well as treatment options for each etiology. Clinicians will frequently encounter women with AUB and should report findings utilizing the PALM-COEIN system.

Comparative study of vaginal danazol vs diphereline (a synthetic GnRH agonist) in the control of bleeding during hysteroscopic myomectomy in women with abnormal uterine bleeding: a randomized controlled clinical trial

OBJECTIVE

To compare the usefulness of vaginal danazol and diphereline in the management of intra-operative bleeding during hysteroscopy.

DESIGN

Randomized controlled clinical trial.

SETTING

University hospital.

PATIENTS

One hundred and ninety participants of reproductive age were enrolled for operative hysteroscopy. Thirty women were excluded from the study.

INTERVENTIONS

One hundred and sixty participants with submucous myomas were allocated at random to receive either vaginal danazol (200mg BID, 30 days before surgery) or intramuscular diphereline (twice with a 28-day interval).

MAIN OUTCOME MEASURES

Severity of intra-operative bleeding, clarity of the visual field, volume of media, operative time, success rate for completion of operation and postoperative complications.

RESULTS

Overall, 145 patients completed the study. In the danazol group, 78.1% of patients experienced no intra-operative uterine bleeding, and 21.9% experienced mild bleeding. In the diphereline group, 19.4% of patients experienced no intra-operative uterine bleeding, but mild, moderate and severe bleeding was observed in 31.9%, 45.8% and 2.8% of patients, respectively. The difference between the groups was significant (p<0.001). A clear visual field was reported more frequently in the danazol group compared with the diphereline group (98.6% vs 29.2%, p<0.001). The mean operative time was 10.9 min and 10.6 min in the danazol and diphereline groups, respectively (p=0.79). The mean volume of infused media was 2.0L in both groups (p=0.99). The success rate was 100% for both groups with no intra-operative complications.

CONCLUSION

Both vaginal danazol and diphereline were effective in controlling uterine bleeding during operative hysteroscopy. However, vaginal danazol provided a clearer visual field.