PREVALENCE A population based study of 1000 adolescents: Incidence of AUB is 40% Out of those who have AUB 20% have bleeding disorders Von Willebrand disease, 5%-36%; Platelet function defects, 2%-44%; Thrombocytopenia, 13%- 20% Clotting factor deficiencies, 8%-9%.

1. AUB in ADOLESCENTS
Dr. Jyoti Bhaskar
Dr. Sharda Jain
Dr. Jyoti Agarwal
…Caring hearts, healing hands

2. PREVALENCE
A population based study of 1000 adolescents:
 Incidence of AUB is 40%
 Out of those who have AUB
20% have bleeding disorders
• Von Willebrand disease, 5%-36%;
• Platelet function defects, 2%-44%;
• Thrombocytopenia, 13%- 20%
• Clotting factor deficiencies, 8%-9%.

3. MENSTRUAL PATTERN

4. CAUSES OF AUB IN ADOLESCENTS

5. ABNORMAL UTERINE BLEEDING
• The most common cause of AUB is
anovulation secondary to a disturbance of
the normal hypothalamic-pituitary-ovarian
axis.
• ACOG considers AUB synonymous with
anovulatory uterine bleeding.

6. PHYSIOLOGY
ANOVULATION – Immaturity of HPO axis
Most common cause of AUB in adolescents
First postmenarchal year – 50% anovulatory
AGE AT MENARCHE DURATION TO
OVULATORY CYCLES
< 12 years 1 year
12-13 3 years
> 13 4.5 years
Wilkinson, Kadir: Management of Abnormal Uterine Bleeding in
Adolescents. J Pediatr Adolesc Gynecol (2010) 23:S22-S30

7. ANOVULATION BLEEDING-
PHYSIOLOGY

8. FURTHER EVALUATION
BEFORE LABELLING AS ANOVULATION RULE OUT OTHER CAUSES
PCOS
THYROID
DISTURBANCES
PREGNANCY
STI
BLEEDING
DISORDERS
MEDICATIONS
SYSTEMIC
ILLNESS
TRAUMA
STRUCTURAL
CAUSES

9. EVALUATION – MAIN POINTS
INITIAL TRIAGE
HAEMODYNAMICALLY
STABILITY
PREGNANCY STATUS
UNSTABLE
HOSPITALISE
STABLE
NEGATIVEPOSITIVE
BETA HCG
TVS
BG AND CM
TESTS FOR BLEEDING
DISORDERS
MISCARRIAGE
ECTOPIC
MOLAR
OTHER CAUSES
OF AUB

10. LABORATORY EVALUATION
• Pregnancy test
• Haemoglobin / Haematocrit with platelet count ( CBC )
• TSH
• S. Prolactin – galactorrhoea or h/o headaches
• PT APTT
• Screen for STI – if indicated
• If Hirsuite --- investigate for PCOS
• Pelvic Ultrasound

11. WHOM TO SCREEN FOR BLEEDING
DISORDERS

12. SUGGESTED APPROACH TO EVALUATION OF BLEEDING DISORDERS
TESTING SHOULD BE DONE BEFORE STARTING HORMONE THERAPY
OR BLOOD TRANSFUSION

13. CLINICAL CLASSIFICATION
DURATION FLOW HAEMOGLOBIN
MILD > 7 OR < 24
FOR 2 MONTHS
MILD TO
MODERATE
10 -12
MODERATE > 7 DAYS MODERATE
TO HEAVY
> 10
SEVERE DISRUPTIVE HEAVY < 10

14. GOALS OF MANAGEMENT
• Establishment and/or maintenance of
hemodynamic stability
• Correction of acute or chronic anaemia
• Return to a pattern of normal menstrual cycles
• Prevention of recurrence
• Prevention of long-term consequences of
anovulation ( eg, anaemia, infertility, endometrial
cancer)

15. CORRECTION OF ANAEMIA
• For girls with mild or moderate AUB and mild,
asymptomatic anemia ( Hb 10 - 12 g/dL), initiate
iron supplementation with 60 mg elemental iron
per day.
• For girls with severe AUB , initiate iron
supplementation as soon as the patient is stable and
able to take pills by mouth. Depending upon the
severity of iron deficiency, use 60 mg of elemental
iron once or twice per day.

16. RATIONALE OF HORMONE THERAPY
I
Administration of exogenous estrogen permits
additional endometrial proliferation, which heals the
sites of endometrial bleeding, and provides
hemostasis
 Administration of progestin stabilizes the
endometrial lining

17. OUR CONCERN
• High doses of estrogen may cause premature
closure of the growth plates, reducing
ultimate adult height.
• However, by the time of menarche, most
female adolescents have already undergone
their growth spurt and achieved
approximately ≥95 percent of adult height.

18. MAXIMUM HEIGHT GAIN AFTER MENARCHE IS only 2 INCHES

19. MONITORING RESPONSE
• Adolescents who are being treated for
anovulatory uterine bleeding should maintain
a menstrual calendar to monitor response to
therapy and subsequent episodes of
anovulatory uterine bleeding .
• Several smart phone "apps," available at no
cost, may facilitate recording.

20. MILD AUB
HAEMOGLOBIN CONTRACEPTION TREATMENT HORMONE
NORMAL NO OBERVATION AND
REASSURANCE
NO
10-12 GM% YES / NO IRON THERAPY YES
KEEP A MENSTRUAL CALENDAR
FOLLOW UP IN 3 MONTHS – UNLESS SEVERE BLEED
RPT CBC

21. MODERATE AUB
 Out Patient Settings
 Hormonal therapy to stabilize endometrial proliferation
and shedding.
 The hormonal therapy regimen depends upon whether
or not the patient is currently bleeding
A 2012 systematic review found no relevant randomized trials evaluating progestin-
only or combined estrogen-progestin therapy in the treatment of anovulatory uterine
bleeding and no consensus about the optimal approach . The dose of estrogen, dose
and type of progestin, and schedule of administration vary widely.

23. ACTIVELY BLEEDING
• Combined estrogen-progestin oral
contraceptives rather than progestin-only
hormone therapy
BECAUSE ESTROGEN PROVIDES HAEMOSTASIS

24. • Monophasic oral contraceptives with a minimum of 30 mcg
ethinyl estradiol to ensure a sufficient amount of estrogen to
prevent breakthrough bleeding
• One pill every eight hours until the bleeding stops (usually within 48 hours )
• One pill every 12 hours for 5 days, then
• One pill once per day for a total of at least 21 days
If bleeding recurs when the dose is decreased to once per day,
twice per day dosing may be necessary for the full 21 days.
• Close follow-up (in person or by phone) is essential while the pills
are being taken two or three times per day.
• High-dose estrogen therapy can cause nausea, which may result
in decreased adherence …. Consider antiemetic

25. PROGESTIN ONLY PILLS
 Only when COC contraindicated or not tolerated
 Progestin-only regimens may be used to mature and
slough the endometrium
 For acute management, oral progestin is preferred
to other progestin-only options
 Micronized oral progesterone is preferred because it
is chemically identical to endogenous progesterone.

26. COUNSELLING
• Instruct patients to take oral micronized progesterone
200 mg every night for the first 12 days of each
calendar month as this regimen seems the easiest for
teenagers to follow.
• It is not a method of contraception.
• If they become sexually active and desire contraception
they will need COC.
• If they have unprotected sexual intercourse while using
progestin-only therapy, emergency contraception may
be warranted.

27. SEVERE BLEEDING
HOSPITALISATION – INDICATIONS
• Hemodynamic instability
• Hemoglobin concentration <7 g/dL or <10 g/dL with active heavy
bleeding
• Home management with daily monitoring may be possible for patients
with hemoglobin between 8 and 10 g/dL if the patient is
hemodynamically stable and the patient and family are reliable and can
maintain close telephone contact.
• Symptomatic anemia (eg, fatigue, lethargy)
• Need for intravenous conjugated estrogen (eg, cannot take oral
medications, continued heavy bleeding after 24 hours of estrogen-
progestin combination therapy) or surgical intervention
• Need for surgical intervention

28. IMPORTANT ----
EVALUATE FOR BLEEDING DISORDERS
• Blood for evaluation of bleeding disorders
should be obtained before administration of
blood products or estrogen (exogenous
estrogen may elevate VWF into the normal
range)
• Involve a Haematologist

29. HORMONE THERAPY
Lower doses of estrogen (eg, 30 or 35 mcg ethinyl estradiol)
●One pill every four to six hours until the bleeding subsides
(usually within 24 hours)
●One pill every eight hours for three days, then
●One pill every 12 hours for up to two weeks
Antiemetic therapy (eg, promethazine 12.5 to 25 mg orally or
per rectum or ondansetron 4 to 8 mg orally) may be
required for girls who are taking more than one pill per day.

30. PARENTERAL ESTROGEN
Reserved for patients with
 Severe anovulatory uterine bleeding who are
unstable and cannot take oral medications
 If bleeding is not controlled after 24 hours of
combination hormonal therapy.

31. PRACTICAL TIPS
• The dose of IV conjugated estrogen is 25 mg
every four to six hours until the bleeding stops.
• No more than six doses should be administered
• Thromboembolism is a potential complication
• Administration of antiemetics one hour before
each dose of IV estrogen may alleviate the side
effects of nausea and vomiting

32. • Bleeding usually subsides within 4 to 24 hours of the
initiation of IV estrogen .
• Hemostatic therapy may be warranted if bleeding
persists beyond 24 hours .
• If bleeding lasts longer than 24 to 48 hours after
initiation of IV estrogen, oral progesterone should be
added to stabilize the endometrium
• Oral progesterone should be discontinued when oral
contraceptive pills are initiated
• After the bleeding subsides, the patient should be
switched to a taper of combination monophasic oral
contraceptive

33. HAEMOSTATIC TREATMENT
• Tranexamic acid is administered orally: 1300 mg three times
per day for up to five days with each menses
• Aminocaproic acid may be administered orally or IV as follows:
Aminocaproic acid 5 g orally during the first hour, followed by a continuous dose
of 1 to 1.25 g per hour; treatment is continued for approximately eight hours or
until the bleeding has been controlled, or
Aminocaproic acid 4 to 5 g IV during the first hour of treatment, followed by a
continuous infusion at a rate of 1 g per hour; treatment is continued for
approximately eight hours or until the bleeding has been controlled.
• Desmopressin is administered IV as follows:
Desmopressin 0.3 mcg/kg IV over 15 to 30 minutes; the dose may be repeated in
48 hours if there is no response

34. MAINTENANCE
• Oral Hormonal Regimes
• LNG –IUS
• DMPA
• NORPLANTS

35. ORAL REGIMES AND FOLLOW UP
HB < 10 GM%
MONOPHASIC COMBINED OC -
CONTINUOUS FOR 3 MONTHS
COC FOR 21 /7 FOR ANOTHER 3-6
MONTHS
DISCONTINUE COC after 6
months AND OBSERVE
HB >10 GM%
Monitor HB
monthly till
Hb > 12

36. Changing the Standard COC
Regimen: Current/Future Ideas
1. Shorten the hormone free interval from 7 days to
3 -5 days to provide greater ovarian suppression and
decrease the incidence/severity of hormone
withdrawal symptoms
2. Extend the # of days of active OCs to greater
than 21 days
3. Add estrogen during the hormone free interval

37. COC REGIMES
• Cyclic: 21/7 OR 24/4
• Extended: 6 weeks on/4 days off or 84/7
• Continuous
*Vaginal ring can also be used in continuous
fashion

38. Treatment of mild, moderate and severe
episodes with known negative pregnancy test
Amount of Bleeding Hb Management/Treatment
Mild
>11
Reassurance, education. Offer iron and low
dose OCP. Reevaluate 3 months
Moderate
9-11
Education. Rule out STD and
coagulopathy. Offer iron and low dose OCP
taper. Reevaluate 2 months.
Severe
7-9
Rule out coagulopathy. Offer iron and high
dose OCP taper. Reevaluate in 4 weeks.
Hypovolemic Shock
<5-6
Stabilize, rule out coagulopathy. Offer
transfusion. Admit for high dose hormones
until VB stops (IV or po route). D&C or
balloon tamponade in extreme cases.