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1/1/2018

Abnormal Uterine Bleeding in Adolescents

Abnormal uterine bleeding (AUB) in adolescents is defined as excessive bleeding occurring between menarche and 19 years of age. During the first 12–18 months after the onset of menstruation, immaturity of the hypothalamic-pituitary axis is believed to result in an inconsistent ‘positive feedback’ response, wherein sustained elevations of periovulatory estradiol cause a reflex surge of Luteinizing Hormone (LH).  This failure of an appropriately timed LH surge results in a sustained elevation of estradiol without ovulation, progesterone production, or a normal luteal phase.  Anovulation is the most common cause of abnormal uterine bleeding during early adolescence. By the third year after menarche, about 75% of menstrual cycles are 21–34 days long.

Adolescents with more than 45 or less than 21 days between menstrual cycles, bleeding lasting longer than 7 days, having a single episode of 3 months between bleeding, or changing sanitary products more often than every 1-2 hours should undergo an evaluation. Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with physical, social, emotional or material quality of life.

Coagulopathy should be considered in adolescents with excessive bruising or bleeding or a family history of a bleeding disorder. Regardless of reported sexual history, pregnancy, sexual trauma, and sexually transmitted infections should be evaluated. Patients should be evaluated for endocrinopathies (such as thyroid disease), stress and eating disorders, and polycystic ovary syndrome (PCOS). Anovulatory cycles associated with obesity and hyperestrogenism can be seen in the absence of PCOS.

Laboratory testing should initially include an assessment of urine or serum β-hCG, a complete blood count with platelets, and TSH. Other testing should be performed based on the history and physical examination and may include androgen levels (free or total testosterone) and prolactin. Von Willebrand disease is the most common bleeding disorder associated with AUB. Approximately one quarter of adolescents who require hospitalization or blood transfusion may have a coagulopathy. Anemia on initial evaluation should trigger further testing for a bleeding disorder including PT, PTT, and a Von Willebrand panel. Pelvic ultrasounds are not typically included in initial testing since structural causes of AUB are rarely seen with adolescents.

The goal of therapy is to decrease excessive bleeding, prevent its recurrence, and improve quality of life. First line therapy includes non-steroidal anti-inflammatory drugs (NSAIDs) through the inhibition of prostaglandins.  Another option includes tranexamic acid, at 1300 mg orally or 10 mg/kg IV (max 600 mg/dose) three times daily for up to 5 days. A trial of oral estradiol or conjugated equine estrogen (with progestin inhibition) or a combined oral contraceptives (COC) can be both diagnostic and therapeutic. In addition to regulating menstrual flow and providing contraception, the practitioner should counsel the adolescent that COC’s can provide relief of associated dysmenorrhea, acne/hirsutism, and premenstrual syndrome, prevent menstrual migraine, and potentially reduce pelvic pain associated with endometriosis. If estrogen is contraindicated, depot medroxyprogesterone acetate (DMPA) or the levonorgestrel intrauterine system can also reliably provide relief for AUB, with a substantial proportion of users achieving amenorrhea within 6 months. Surgery or blood transfusions is often unnecessary in adolescents since they often respond well to medical management and tolerate anemia well. Rarely, incessant bleeding can become a medical emergency that requires hospitalization and more intense evaluation including a pelvic exam, ultrasound, and treatment including intravenous estrogen, fibrinolytics, and in rare cases, surgical intervention.

Follow up for management is essential for the adolescent patient as possible underlying conditions need to be worked out, quality of life monitored and long-term menstrual bleeding control may need to be considered.   

Further Reading:

ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol. 2015 Dec;126(6):e143-e146. doi: 10.1097/AOG.0000000000001215. PMID: 26595586.

 

ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-896. doi: 10.1097/01.AOG.0000428646.67925.9a. PMID: 23635706.

 

Yaşa C, Güngör Uğurlucan F. Approach to Abnormal Uterine Bleeding in Adolescents. J Clin Res Pediatr Endocrinol. 2020 Feb 6;12(Suppl 1):1-6. doi: 10.4274/jcrpe.galenos.2019.2019.S0200. PMID: 32041387; PMCID: PMC7053441.

Initial Approval: November 2017; Reaffirmed May 2019; Revised March 21, Revised July 2022

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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