Abnormal Uterine Bleeding in Adolescents: Diagnosis and Management

Abstract

Abnormal uterine bleeding AUB is a frequent cause of visits to health care provider during adolescent period. Although many etiologies cause AUB, the most likely cause among adolescents are dysfunctional uterine bleeding DUB . Any kind of bleeeding when all possible causes are excluded is termed as DUB. Anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis is the leading cause during perimenarchal years. Bleeding disorders especially von Willebrand disease should always be kept in mind while evaluating an adolescent presenting with menorrhagia. Initial evaluation of the patient starts with detailed clinical history, complete physical examination and followed by labarotary tests which includes complete blood count, coagulation profile, serum pregnancy test and hormonal evaluation if indicated. Treatment depends on the severity of bleeding. Management in mild cases consist of reassurance of adolescent and her parents. Moderate and severe cases of DUB usually require medical treatment. Treatment options are combined oral contraceptives COCs , progestogens, non steroidal anti inflammatory drugs NSAIDs , antifibrinolytic agents and GnRH analogues. Iron supplementation is usually required in case of anemia.

Keywords

• Abnormal uterine bleeding,bleeding disorder,adolescent

Adolesanlarda Anormal Uterin Kanama: Tanı ve Yönetim

Abstract

Anormal uterin kanama AUK adolesan dönmede sağlık kuruluşlarına başvurunun sık görülen nedenlerinden biridir. AUK etyolojisinde birçok neden görülse de, adolesanlar arasında en sık rastlanılan sebep disfonksiyonel uterin kanamadır DUK .Bütün nedenler dışlandığında görülen kanama DUK olarak isimlendirilmektedir. Hipotalamo-pitüiter-ovaryan aksın immatüritesine bağlı anovulasyon, perimenarşal yıllarda en sık görülen nedendir. Menoraji nedeni ile başvuran adolesanda, kanama diatezleri, özellikle de von Willebrand hastalığı daima akılda tutulmalıdır. Hastanın değerlendirilmesi ilk olarak detaylı bir anamnez, tam fizik muayene ve tam kan sayımı, koagülasyon parametreleri, serum gebelik testi ve hormon profilini içeren labaratuvar testleri ile başlamalıdır. Tedavi kanamanın şiddetine göre değişmektedir. Hafif kanamalarda hasta ve ailesinin bilgilendirilmesi yeterli olurken, orta ve şiddetli kanamalarda medikal tedavi gerekmektedir. Kombine oral kontraseptifler, progestojenler, non-steroidal anti-inflamatuar ajanlar, anti-fibrinolitik ajanlar ve GnRH analogları tedavide kullanılan ajanlardır. Anemi varlığında demir replasmanı da gerekmektedir.

Keywords

• Anormal uterin kanama,kanama diatezi,adolesan

References

1. 1. Caufriez A. Menstrual disorders in adolescence: pathophysiology and treatment. Horm Res. 1991;36:156-9.
2. 2. Deligeoroglou E, Karountzos V, Creatsas G. Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. Gynecol Endocrinol. 2013;29:74-8.
3. 3. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 81, May 2007. ACOG Committee on Practice Bulletins. Obstet Gynecol. 2007;109:1233-48.
4. 4. American Academy of Pediatrics, Committee on Adolescence, American College of Obstetricians and Gynecologists and Committee on Adolescent Health Care. Menstruation in girls and adolescents: Using the manstrual cycle as a vital sign. Pediatrics. 2006;118: 2245-2250.
5. 5. Gray SH, Emans SJ. Abnormal vaginal bleeding in adolescents. Pediatr Rev. 2007;28:175-82.
6. 6. Deligeoroglou E, Tsimaris P. Menstrual disturbances in puberty. Best Pract Res Clin Obstet Gynaecol. 2010;24:157-71.
7. 7. Apter D, Vihko R. Early menarche, a risk factor for breast cancer, indicates early onset of ovulatory cycles. J Clin Endocrinol Metab. 1983;57:82-6.
8. 8. Vihko R, Apter D. Endocrine characteristics of adolescent menstrual cycles: impact of early menarche. J Steroid Biochem. 1984;20:231-6. 9. Smith SK, Abel M H, Kelly RW, Baird DT. Prostaglandin synthesis in the endometrium of women with ovular dysfunctional uterine bleeding.Br J Obstet Gynaecol. 1981;88:434-42.

9. 10. James AH. More than menorrhagia: a review of the obstetric and gynaecological manifestations of bleeding disorders.Haemophilia. 2005;11:295-307.
10. 11. López JA, Andrews RK, Afshar-Kharghan V, Berndt MC. BernardSoulier syndrome.Blood. 1998;91:4397-418.
11. 12. George JN, Caen JP, Nurden AT. Glanzmann’s thrombasthenia: the spectrum of clinical disease.Blood. 1990;75:1383-95.
12. 13. Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALMCOEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age.Int J Gynaecol Obstet. 2011;113:3-13.
13. 14. James AH. Bleeding disorders in adolescents.Obstet Gynecol Clin North Am. 2009;36:153-62.
14. 15. Bravender T, Emans SJ. Menstrual disorders. Dysfunctional uterine bleeding. Pediatr Clin North Am. 1999; 46:545-53
15. 16. Middeldorp S, Meijers JC, van den Ende AE, van Enk A, Bouma BN, Tans G, Rosing J, Prins MH, Büller HR. Effects on coagulation of levonorgestrel and desogestrel containing low dose oral contraceptives: a cross-over study.Thromb Haemost. 2000;84:4-8
16. 17. Rimsza ME. Dysfunctional uterine bleeding.Pediatr Rev. 2002;23:227-33.
17. 18. Strickland JL, Wall JW. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am. 2003;30:321-35.
18. 19. Deligeoroglou E, Karountzos V, Creatsas G. Abnormal uterine bleeding and dysfunctional uterine bleeding in adolescence: diagnosis, management and treatment. Revista Medicana Romana. 2012;59:272-277.
19. 20. Mitan LA, Slap GB. Adolescent menstrual disorders. Update. Med Clin North Am. 2000;84:851-68.
20. 21. Fraser IS. Treatment of ovulatory and anovulatory dysfunctional uterine bleeding with oral progestogens. Aust N Z J Obstet Gynaecol. 1990;30:353-6.
21. 22. Cowan BD, Morrison JC. Management of abnormal genital bleeding in girls and women. N Engl J Med. 1991;324:1710-5.
22. 23. Slap GB. Menstrual disorders in adolescence.Best Pract Res Clin Obstet Gynaecol. 2003;17:75-92.
23. 24. Zreik TG, Odunsi K, Cass I, Olive DL, Sarrel P. A case of fatal pulmonary thromboembolism associated with the use of intravenous estrogen therapy. Fertil Steril. 1999;71:373-5
24. 25. Mannucci PM. Treatment of von Willebrand disease. Haemophilia. 1998;4: 661-4.
25. 26. Kriplani A, Kulshrestha V, Agarwal N, Diwakar S. Role of tranexamic acid in management of dysfunctional uterine bleeding in comparison with medroxy progesterone acetate.J Obstet Gynaecol. 2006; 26:673-8.
26. 27. Speroff L, Glass RH, Kase NG. Abnormal uterine bleeding. In Speroff L, Glass RH, Kase NG, editors. Clinical gynecologic endocrinology and infertility. 8th.Edition. Baltimore: Williams&Wilkins; p:591-620.