Anormal Uterin Kanamalı Adölesanların Multidisipliner Yaklaşım ile Yönetiminin Değerlendirilmesi

Öz

Anormal uterin kanama (AUK), uterus korpusundan süre, miktar, sıklık ve/veya düzen açısından anormal olan kanama olarak tanımlanır. Adölesan dönemde en sık karşılaşılan jinekoendokrinolojik problemdir. Çalışmamızda AUK olan 40 adölesanın verileri retrospektif olarak incelendi. Hemoglobin 10-12 gr/dL hafif AUK; hemoglobin 8-9,9 gr/dL orta AUK; hemoglobin <8 gr/dL ağır AUK olarak sınıflandırıldı. Olguların yaş ortalaması 14,38±2,1 (11-17,8) yıldı. Olguların ortanca menstrual siklus aralığı 25 (10-45) gün, ortanca kanama süresi 10 (4-35) gün, ortalama ped sayısı 6,2 ped/gün idi. Olguların %17.5’inde (n=7) ağır AUK, %20’sinde (n=8) orta AUK, %62,5’inde (n=25) hafif AUK mevcuttu. 2 (%5) olguda hafif Von Willebrand Hastalığı saptandı. Kanama etiyolojisinde saptanan en sık etken anovulasyondu (n=34). Hafif AUK olan olgularda kanamaya yönelik tedavide ilk seçenek olarak non-steroid antiinflamatuar ilaçlar (NSAİİ) başlandı. Orta AUK olan adölesanlara (n=8) ve hafif AUK olup NSAİİ ile kanamaları kontrol altın alınamayan olgulara (n=6) 3mg drospirenon ve 30 mcg etinilöstradiol içeren kombine oral kontraseptif (KOK) başlandı. Bu olguların kanamaları KOK ile kontrol altına alındı. Ağır AUK olan olgulara, 3mg drospirenon ve 30 mcg etinilöstradiol içeren KOK günde 2-3 tablet olacak şekilde başlandı. Bu olguların kanamalarının kontrol altına alınamaması nedeniyle tedavilerine traneksamik asit oral olarak eklendi. Ağır AUK olan tüm olgularda kombine tedavi ile kanamalar kontrol altına alındı. Sonuç olarak; adölesan dönemde aşırı ve uzun süreli kanama sadece jinekolojik bir sorun değil, aynı zamanda sosyal bir sorundur. Bu nedenle hastalar çocuk endokrinoloji ve çocuk hematoloji tarafından kapsamlı olarak değerlendirilmeli ve tedavileri multidisipliner olarak planlanmalıdır.

Anahtar Kelimeler

• anormal uterin kanama
• anemi
• Von Willebrand Hastalığı

Evaluation of the Management of Adolescents with Abnormal Uterine Bleeding with a Multidisciplinary Approach

Öz

Abnormal uterine bleeding (AUB) refers to atypical uterine corpus bleeding characterized by duration, volume, frequency, and/or pattern deviations. It represents a prevalent gynecological endocrine issue among adolescents. This retrospective study analyzed data from 40 adolescent patients diagnosed with AUB. Severity of AUB was categorized based on hemoglobin levels: mild (10-12 g/dL), moderate (8-9.9 g/dL), and severe (<8 g/dL). The mean age of the cohort was 14.38±2.1 years (range: 11-17.8 years). Median menstrual cycle interval was 25 days (range: 10-45 days), median bleeding duration was 10 days (range: 4-35 days), and mean sanitary pad usage was 6.2 pads per day. Severe AUB was observed in 17.5% (n=7) of cases, moderate AUB in 20% (n=8), and mild AUB in 62.5% (n=25). Mild Von Willebrand Disease was diagnosed in 5% (n=2) of patients. Anovulation was the predominant etiological factor in 34 cases. Treatment protocols varied based on AUB severity. Non-steroidal anti-inflammatory drugs (NSAIDs) constituted the initial therapy for mild AUB. Adolescents with moderate AUB (n=8) and those with mild AUB unresponsive to NSAIDs (n=6) were prescribed combined oral contraceptives (COCs) containing 3mg drospirenone and 30 mcg ethinylestradiol. Severe AUB cases commenced COC therapy at escalated dosages (2-3 daily tablets), supplemented with oral tranexamic acid when bleeding remained uncontrolled. In conclusion, excessive and prolonged bleeding during adolescence poses both gynecological and social challenges. Comprehensive evaluation by pediatric endocrinologists and pediatric hematologists is essential for effective multidisciplinary treatment planning.

Anahtar Kelimeler

• abnormal uterine bleeding
• anemia
• Von Willebrand Disease

Kaynakça

1. 1. Munro MG, Critchley HOD, Fraser IS, Haththotuwa R, Kriplani A, Bahamondes L, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet [Internet]. 2018 Dec 1 [cited 2024 Jun 14];143(3):393–408.
2. 2. Elmaoğulları S, Aycan Z. Abnormal Uterine Bleeding in Adolescents. J Clin Res Pediatr Endocrinol [Internet]. 2018 Sep 1 [cited 2024 Jun 14];10(3):191–7.
3. 3. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet [Internet]. 2001 [cited 2024 Jun 14];72(3):263–71.
4. 4. Yaşa C, Uğurlucan FG. Approach to Abnormal Uterine Bleeding in Adolescents. J Clin Res Pediatr Endocrinol [Internet]. 2020 [cited 2024 Jun 14];12(Suppl 1):1–6.
5. 5. Haamid F, Sass AE, Dietrich JE. Heavy Menstrual Bleeding in Adolescents. J Pediatr Adolesc Gynecol [Internet]. 2017 Jun 1 [cited 2024 Jun 14];30(3):335–40.
6. 6. Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet [Internet]. 2011 [cited 2024 Jun 14];113(1):3–13.
7. 7. Liu Z, Doan Q V., Blumenthal P, Dubois RW. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health [Internet]. 2007 [cited 2024 Jun 14];10(3):183–94.
8. 8. Elmaoğulları S, Aycan Z. Adolesanlarda Anormal Uterin Kanamalar. In: Darendeliler F, Aycan Z, Kara C, Özen S, Eren E, editors. Çocuk Endokrinolojisi ve Diyabet. İstanbul Medikal Sağlık ve Yayıncılık; 2021. p. 830–9.

9. 9. Çetin SK, Aycan Z, Özsu E, Şıklar Z, Ceran A, Karaca SE, et al. Evaluation of Abnormal Uterine Bleeding in Adolescents: Single Center Experience. J Clin Res Pediatr Endocrinol [Internet]. 2023 [cited 2024 Jun 14];15(3):230–7.
10. 10. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol [Internet]. 2013 Apr [cited 2024 Oct 2];121(4):891–6.
11. 11. C D, C D, M D, J D. Gynaecological and obstetric management of women with inherited bleeding disorders. Int J Gynaecol Obstet [Internet]. 2006 Oct [cited 2024 Oct 2];95(1):75–87.
12. 12. Rimsza ME. Dysfunctional uterine bleeding. Pediatr Rev [Internet]. 2002 [cited 2024 Jun 14];23(7):227–33.
13. 13. ACOG Committee Opinion No. 349, November 2006: Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol [Internet]. 2006 [cited 2024 Jun 14];108(5):1323–8.
14. 14. Gray SH, Emans SJ. Abnormal vaginal bleeding in adolescents. Pediatr Rev [Internet]. 2007 May [cited 2024 Jun 14];28(5):175–82.
15. 15. Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol [Internet]. 1981 [cited 2024 Jun 14];139(3):277–80.
16. 16. Pecchioli Y, Oyewumi L, Allen LM, Kives S. The Utility of Routine Ultrasound in the Diagnosis and Management of Adolescents with Abnormal Uterine Bleeding. J Pediatr Adolesc Gynecol [Internet]. 2017 Apr 1 [cited 2024 Jun 14];30(2):239–42.
17. 17. Bumbuliene Z, Sragyte D, Klimasenko J, Bumbul-Mazurek E. Abnormal uterine bleeding in adolescents: ultrasound evaluation of uterine volume. Gynecol Endocrinol [Internet]. 2019 Apr 3 [cited 2024 Jun 14];35(4):356–9.
18. 18. Shankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. von Willebrand disease in women with menorrhagia: a systematic review. BJOG [Internet]. 2004 Jul [cited 2024 Jun 14];111(7):734–40.
19. 19. Chi C, Pollard D, Tuddenham EGD, Kadir RA. Menorrhagia in adolescents with inherited bleeding disorders. J Pediatr Adolesc Gynecol [Internet]. 2010 Aug [cited 2024 Jun 14];23(4):215–22.
20. 20. Díaz R, Dietrich JE, Mahoney D, Yee DL, Srivaths L V. Hemostatic abnormalities in young females with heavy menstrual bleeding. J Pediatr Adolesc Gynecol [Internet]. 2014 Dec 1 [cited 2024 Jun 14];27(6):324–9.
21. 21. Vural Ö, Sen HS, Eker İ. Hematolog Approach to Abnormal Uterine Bleeding in Adolescents. Guncel Pediatr. 2023;21(1):92–7.
22. 22. Kanbur NO, Derman O, Kutluk T, Gürgey A. Coagulation disorders as the cause of menorrhagia in adolescents. Int J Adolesc Med Health [Internet]. 2004 [cited 2024 Jun 14];16(2):183–5.
23. 23. Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Glob Heal [Internet]. 2013 Sep [cited 2024 Jun 14];1(1).
24. 24. Camaschella C. Iron deficiency. Blood [Internet]. 2019 Jan 3 [cited 2024 Jun 14];133(1):30–9. Available from: https://pubmed.ncbi.nlm.nih.gov/30401704/
25. 25. Knol HM, Mulder AB, Bogchelman DH, Kluin-Nelemans HC, Van Der Zee AGJ, Meijer K. The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalities. Am J Obstet Gynecol [Internet]. 2013 [cited 2024 Jun 14];209(3):202.e1-202.e7.
26. 26. Benjamins LJ. Practice guideline: evaluation and management of abnormal vaginal bleeding in adolescents. J Pediatr Health Care [Internet]. 2009 May [cited 2024 Jun 24];23(3):189–93.
27. 27. Sokkary N, Dietrich JE. Management of heavy menstrual bleeding in adolescents. Curr Opin Obstet Gynecol [Internet]. 2012 Oct [cited 2024 Jun 24];24(5):275–80.
28. 28. Frishman GN. Evaluation and treatment of menorrhagia in an adolescent population. J Minim Invasive Gynecol [Internet]. 2008 Nov [cited 2024 Jun 24];15(6):682–8.
29. 29. Hernandez A, Dietrich JE. Abnormal Uterine Bleeding in the Adolescent. Obstet Gynecol [Internet]. 2020 Mar 1 [cited 2024 Jun 24];135(3):615–21.
30. 30. Duffy DM, Dozier BL, Seachord CL. Prostaglandin dehydrogenase and prostaglandin levels in periovulatory follicles: implications for control of primate ovulation by prostaglandin E2. J Clin Endocrinol Metab [Internet]. 2005 Feb [cited 2024 Oct 1];90(2):1021–7.
31. 31. Expression of prostaglandin metabolising enzymes COX-2 and 15-PGDH and VDR in human granulosa cells - PubMed [Internet]. [cited 2024 Oct 1].
32. 32. H L, R H. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health [Internet]. 2012 Aug [cited 2024 Oct 4];4:413.
33. 33. Fraser IS, McCarron G. Randomized trial of 2 hormonal and 2 prostaglandin-inhibiting agents in women with a complaint of menorrhagia. Aust N Z J Obstet Gynaecol [Internet]. 1991 [cited 2024 Jun 24];31(1):66–70.
34. 34. Lethaby A, Wise MR, Weterings MAJ, Rodriguez MB, Brown J. Combined hormonal contraceptives for heavy menstrual bleeding. Cochrane database Syst Rev [Internet]. 2019 [cited 2024 Jun 24];2(2).