AUB Management in Adolescent Taheripanah R IRHRC Shahid
AUB Management in Adolescent Taheripanah. R IRHRC Shahid Beheshti Medical University October 2012
Epidemiology in Adolescent o o 1 in every 5 women during her life Very common in the first 2 -3 years after menarche due to immature the positive and negative feedback systems of the hypothalamicpituitary-ovarian axis 85% cycles are anovulatory in 3 first years Earlier menarche achieve regular ovulation earlier than those who menstruate later (Vihko, J Steroid Biochem. 1984
Etiology of AUB in Adolescent o Endocrine disorders n n n o n n n n Cervicitis Vaginitis Endometritis PID n n n o o Thrombocytopenia(ITP, Leukemia, Anemia Apelastic) Clotting disorders (Von Wilberraound, Platlet disorders Medications n Threatened abortion Ectopic pregnancy GTN Infection Bleeding disorders n Pregnancy-related Complications n o Hypo- or hyperthyroidism Adrenal disease Hyperprolactinemia Polycystic ovary syndrome Ovarian failure o Hormonal contraceptives Anticoagulants Platelet inhibitors Androgens Spironolactone Antipsychotics Trauma Ovarian problems Systemic diseases Cervical cancers
Medical treatment of DUB o o o Iron NSAIDS Antifibrinolytic* Progestins Estrogen+ progetsins Parenteral Estrogen n *(Trans examinic acid FDA approved November 2009)
Iron o o o Menstrual volume >80 Cc may cause iron deficiency anemia Primary symptom is fatigue Daily doses of oral iron
Non Steroidal Anti-inflammatory Drugs o o NSAIDs have been shown to be effective in the treatment of menorrhagia although not superior to other medical therapies* Sodium Naproxen - 220 mg Preemptive treatment -start day prior to menses need to clarify and identify premenstrual alert system 440 mg twice daily with meals for cycle *Lethaby A, et al. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding (Cochrane Review) 2001
Tranexaminic Acid o o Worldwide use for over 40 years Is available over the counter in Europe Injectable was approved by the FDA in USA in 1986 for use in patient with hemophilia and tooth extractions Used in severe trauma cases
Tranexamic Acid o o Women with hypermenorrhea may have elevated levels of plasminogen activators in the endometrium* “Inhibits fibrinolysis *Kauntiz, AM. OBG Management Vol 22, No. 6 June 2010 o o The first non--hormonal treatment for DUB to be approved by the FDA Nov 2009 Dosage: two 650 mg (1, 300 mg) three times a day for five days
Tranexamic Acid o Rapid response with first cycle o Excellent response in AUB in all age groups o Excellent response in patients with fibroids *Lukes, AS. Et al. Obstet Gynecol. 2010; 116: 865 -875.
Hormonal Therapy o o o Primary purpose is to stabilize endometrial proliferation and promote bleeding >90% of adolescents with DUB respond to hormonal therapy(50% improvement) Estrogen “heals” sites of bleeding by causing further proliferation and providing hemostasis Progesterone stops proliferation and stabilizes the endometrial lining Estrogen has effect on platelet lipid profile and increase the coagulation
Treatment: Mild DUB o o o Longer than normal menses or shotened cycles for >2 months Observation and Reassurance If anemia is not present/normal physical exam Menstural calendar recommended despite normal hmeoglobin Follow up in 3 -6 months
Treatment: Moderate DUB o o o o o Moderately prolonged or frequent menses every 1 -3 weeks with moderate -heavy menstrual flow Mild anemia is often present without signs of hypovolemia Outpatient management with hormonal therapy Acute bleeding : combination oral contraceptives in tapering doses( minimum 30 mcg estrdiol) 1 pill TID until bleeding ceases 1 pill BID * 5 days 1 pill Qd*21 days No active bleeding. daily/cyclic OCP Progestin-only regimens are an alternative option. MPA 10 mg*first 12 days of the month
Treatment: Severe DUB o o o Heavy menstrual bleeding causing a decrease in hgb<10 with or without hemodynamic instability Hospitalization indicates include: Initial hgb<7 g/dl Orthostatic signs Heavy active bleeding with hgb<10 g/dl Girls who require hospitalization should undergo evaluation for a bleeding disorder
Treatment : Severe DUB o Combination OCPs (estradiol 50 mcg) n n o Conjugated IV estrogen 25 mg IV Q 4 -6 is required for unstable patients n n o o 1 pill Q 4 until bleeding subsides(usualy within 24 hrs) 1 pill QID *4 days 1 pill TID *3 days 1 pill BID *2 weeks No more than 6 doses Bleeding subsides 4 -24 hrs Persistent bleeding >24 hrs requires hemostatic therapy (anti-fibrinolytic )or uterine curettage should be considered (rare) Combined OCPs should be initiated within 24 -48 hrs of Iv estrogen Anti-emetic therapy is recommended 2 hrs before ocp Blood transfusion is indicated in symptomatic patients
Maintenance Therapy o Combination OCPs n Without significant anemia(hgb>10) o n With significant anemia (hgb<10) o o o Cyclic therapy w/21 days +7 days placebo Continuous daily OCPs(no placebo) until hgb returns to normal (-3 mo) followed by cyclic therapy for total of 6 months Discontinue hormonal therapy after 3 -6 months to determine if a normal menstrual pattern has been established Progetins-only regimens (10 mmg QD*first 12 days of months is an alternative in patients who do not prefer contraception
Levonorgesterol releasing IUD o It isn’t recommended in adolescent
Surgical treatment od DUB in Adolescents o o o Surgical treatment with dilatation and curettage is the last option Myomectomy Polypectomy
Conclusion o o AUB is very common in adolescent The most common etiology is the endocrine disorders Hormonal therapy is useful in moderate bleeding Maintenance therapy is recommended for 3 -6 months
Thanks for Your Attention
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