This document discusses abnormal uterine bleeding (AUB) or menorrhagia in puberty. It lists various potential causes of AUB including anovulation, polyps, adenomyosis, leiomyoma, and bleeding disorders. Anovulation due to an immature hypothalamic-pituitary-ovarian axis is the most common cause. The document provides guidelines on evaluating AUB, including taking a detailed history, physical exam, lab tests, and ultrasound. Differential diagnoses are discussed. Bleeding disorders are more commonly platelet dysfunction disorders in Southeast Asia, unlike the West where Von Willebrand disease is more common.

1. Puberty
Menorrhagia
Dr.
Kawita
Bapat

2. Abnormal
Menstrual
Bleeding
Polyp
Adenomyosis
Leiomyoma
Malignancy
&
Hyperplasia
Submucosal
Other
Cogulopathy
Ovulatory
DysfuncDon
Endometrial
Latrogenic
Not
yet
classified

3. What
is
normal
blood
loss?
• There
is
considerable
cycle
variability
in
the
adolescent
years.
• Regular
ovulatory
menstrual
cycles
occur
every
21
to
35
days
and
• Last
up
to
7
days,
with
an
average
blood
loss
of
25
to
69
mL.
• Many
paDents
complain
of
menstrual
problems
• that
actually
fall
within
normal
variaDons.
• In
the
first
year
of
aUer
menarche,
50%
of
cycles
are
anovulatory
• But
80
%
sDll
fall
in
the
normal
range
for
duraDon.

4. What
is
normal
blood
loss?
• By
the
third
year
of
menarche,
95%
of
menstrual
cycles
fall
into
this
range.
• CharDng
the
menstrual
flow
on
a
calendar
can
be
helpful
to
clarify
normal
versus
abnormal
cycles.
• Cycles
that
fall
outside
of
the
norm
should
be
evaluated
for
underlying
pathology.

5. History
• Amenorrhea
followed
by
prolonged
HMB-­‐PCOS/
anovulatory
cycles.
• Sexual
history
• Bleeding
diethesis
• MedicaDons
• Renal
disease
• Liver
disease
• Family
H/o
bleeding
disorder

6. Detail
Menstrual
History
• Age
at
menarche
• Timing,
duraDon
and
quanDty
of
her
uterine
bleeding.
• Cramping
and/or
clots
• Should
address
physiological
stressors
• Weight
changes
• EaDng
and
• Excercise
habits
EffecDve
history
taking
from
an
adolescent
requires
parDcular
skills
and
sensiDviDes

7. Physical
exam-­‐
D/D
guided
• Hemodynamic
status
acute
/
chronic
• Degree
of
anaemia
• Features
of
bleeding
diethesis
• Features
of
PCOS
/
BMI
• Features
of
other
endocrinopathies
• P/S
&
P/V
if
sexually
acDve

8. ObjecDve
DefiniDon
• Prolonged
-­‐
more
than
7
days
bleeding
or
• Excess
blood
loss
>
80ml
/
menstrual
cycle
• PaDent
comes
with
diagnosis.....
You
need
to
find
out
the
cause

9. AeDology
•
HPO
dysfuncDon
50%-­‐
anovulatory
cycles-­‐est
hyperplasia
• Blood
dyscrasia
,20%
-­‐
coag
disorders,
thrombocytopenic
purpura.
• Von
Wilebrand's
Disease,
leukemia
• PCOD
10-­‐12%
• Hypothyroidism
4%
• Genital
tuberculosis
4%,
Liver
disorders
• Feminizing
ovarian
tumors-­‐granula
cell
and
theca
cell
tumors
• Adrenal
hyperplasia

10. Causes
• While
there
are
mulDple
causes
for
abnormal
uterine
bleeding
in
adolescents,
• The
most
likely
cause
is
dysfuncDonal
uterine
bleeding
(DUB)
due
to
an
immature
hypothalamic-­‐
pituitary
-­‐
ovarian
(HPO)
axis
• Causing
anovulatory
cycles
&
irregular
bleeding
• Before
the
diagnosis
of
immature
HPO
exis
can
be
assumed,
more
serious
disorders
must
be
ruled
out.

11. AnovulaDon
is
the
major
cause
• 74.28%
of
cases
of
Puberty
Menorrhagia
• Were
due
to
anovulaDon
dysfuncDonal
uterine
bleeding.
• Chaudhury
et
al
reported
71%6
,
• Roychowdhury
61.5%7,
Neinstein
95%8
of
cases
of
Puberty
menorrhagia
as
being
due
to
anovulaDon
due
to
immaturity
of
hypothalamic
pituitary
ovarian
axis.

12. PCOS
in
Adolescence
• Menstrual
disturbance
is
likely
to
be
the
• Main
issue
for
adolescents
with
PCOS
but
• The
established
long
term
risks
of
obesity,
• SubferDlity
and
diabetes
as
well
as
the
possible
risks
of
endometrial
hyperplasia
and
carcinoma
(Hardiman
et
al
..2003)
and
• Cardiovascular
disease
(recently
reviewed
by
Raj
kaowah
et
al
2000)
and
breast
cancer
(balen,
2001)
require
consideraDon.

13. InvesDgaDon
• UPT
• CBC
• USG
• Bleeding
disorder
• Thyroid
funcDon
test/PRL
• PCOS
tests
if
needed
• Pelvic
USG-­‐PCOD
fibroids

14. DifferenDal
diagnosis
• Immature
HPO-­‐
anovulatory
cycles
-­‐
1
yr
aUer
menarche
85%
/4
yr
aUer
menarche
44%
• Bleeding
diathesis
• PCOS-­‐5-­‐10%
endometrial
hyperplasia
• Other
endocrinopathies-­‐hypo/hyper
thyroid/Cushing
• Pregnancy
and
related
condiDons-­‐many
r
sexually
acDve
• DuplicaDon
of
mullerian
system
• Polyp
and
fibroids
• Pelvic
infecDons
• MedicaDons-­‐hormones-­‐anDdepressant/anDcoagulant

15. Bleeding
disorders
in
South
East
Asia
• The
majority
of
studies
in
the
West
report
• Von
willebrand
disease
as
the
most
common
inherited
bleeding
disorder
• Leading
to
menorrhagia
whereas
studies
in
in
south
east
asia
• Have
found
platelet
funcDon
disorders
is
the
leading
inherited
bleeding
disorder
in
women
with
menorrhagia.

16. Is
USG
needed
in
iniDal
evaluaDon??
1. RetrospecDve
chart
review
of
230
paDents
<
than
18
years
old
presenDng
with
AUB
to
the
gynaecology
clinic
• The
most
common
diagnosis
in
both
the
ultrasound
group
and
non
ultrasound
group
with
AUB
due
to
an
immature
HPO
axis
• Of
the
paDents
who
received
an
ultrasound,
72.4%
had
normal
findings,
incidental
findings
were
idenDfied
in
17.9%
and
PCOS
morphology
in
6.4
• Structural
causes
of
AUB
found
in
only
2
(1.3%)
of
the
adolescents
imaged.
• No
paDent
had
a
change
in
her
AUB
management
plant
due
to
ultrasound
findings
• Pelvic
ultrasound
is
not
required
in
the
iniDal
invesDgaDon
of
AUB
in
the
adolescence
populaDon

17. Lab
work
• ACOG
recommend
that
all
paDents
younger
than
18
who
present
with
abnormal
uterine
bleeding
• Be
screened
for
coagulaDon
disorders,
parDcularly
von
willebrand
disease,
as
this
disorder
has
a
prevalence
of
1%
and
is
the
most
common
disorder
that
causes
menorrhagia
at
menarche.
• Screening
for
such
disorders
should
include
the
parDal
thromboplasDn
Dme,
prothrombin
Dme,
and
assessment
of
platelet
funcDon,
plasma
VWF
acDviDy
(ristoceDn
cofactor
acDvity)

18. Bleeding
disorders
• young
girls
with
blood
coagulopathies
are
at
high
risk
abnormal
bleeding
with
the
onset
of
menarche,
• Bleeding
is
usually
heavy
causing
anaemia
and
may
require
blood
transfusion
• Claessen
et
al
found
20%
of
cases
of
menorrhagia
to
be
due
to
primary
coagulaDon
disorders
• In
our
study
4(11.4%)
paDents
had
coagulaDon
defects.
• Platelet
funcDon
defects
are
an
important
cause
of
menorrhagia
• Saxena
14
et
al
found
platelet
funcDon
disorder
in
83%
of
women
with
menorrhagia
due
to
coagulaDon
defects.

19. Frequently
diagnosed
bleeding
disorders
• Von
Willebrand
Disease
• Mild
platelet
funcDon
disorders
• Mild
factor
deficiency-­‐eg
factor
XI

20. criteria
prompDng
evaluaDon
of
bleeding
disorders
• personal
H/O-­‐>/
I
of
the
following
sym
-­‐
Epistaxis-­‐>
10
min
requiring
medical
anenDon
-­‐
Spontaneous
bruising
>
2
cm
/
minor
wound
bleeding
>
5
min
-­‐
Bleeding
from
oral
cavity/GIT
without
obvious
lesiaon
-­‐
Prolonged/
excessive
bleeding
aUer
surgery
-­‐
Hemorrhage
requiring
BT

21. criteria
prompDng
evaluaDon
of
bleeding
disorders
• family
history
of
• Bleeding
disorder
• Significant
bleeding
complicaDon
not
yet
invesDgated
• HMB
since
menarche
• HGE
from
Corpus
luteum

22. bleeding
disorder
invesDgaDons
• 1st
line-­‐
-­‐
CBC/PS/
APTT/
PT/TT
-­‐
FerriDn/KFT/
LFT/TSH
-­‐
VWF-­‐Ag
,
VWF-­‐
Rco-­‐
ristoceDn
cofactor
acDvity
• 2nd
line-­‐
-­‐
Repeat
VWF
Ag,
VWF-­‐
Rco-­‐F
VIII
-­‐
Platelet
funcDon
tests
• 3rd
line-­‐
• Factor
assays-­‐
II,
V,
VII,
XI,
XIII
• Further
sub
specialised
tests-­‐
in
consultaDon
with
hematologist

23. Mgt
Aim
• Control
menorrhagia
• Prevent
or
treat
anaemia
• Prevent
recurrence
• Treat
the
cause

24. Management
Determining
factors
of
four
treatment:-­‐
• Underlying
eDology
• PaDents
need
for
contracepDon
• Her
adherence/compliance
capabiliDes
• Acceptability
of
adverse
effects/
costs
• There
is
significant
over
leU
in
the
management
of
pts
with
and
without
bleeding
disorders

25. MulDple
modaliDes
• NSAIDS
• AnDfibrinolyDcs
• Hormonal
• DDAVP
• Replacement
of
missing
coagulaDon
factor

26. 1st
line-­‐
non
hormonal
• NSAIDS-­‐
ibuprofen,
Naproxen,
Mefenamic
acid
• AnDfibrinolyDcs-­‐
trenexamc
acid/VWF/
zpfd
• First
line
treatment
in
mild
cases
is
tranexamic
acid
and
NSAIDS
during
the
menstrual
cycle
• Tranexamic
acid
is
effecDve,safe,
the
bio
availability
is
35%
which
requires
administraDon
of
at
least
1
gm
4-­‐6
hourly

27. Mild
DUB-­‐
hemodynamically
stable
• Hb>
10gm%
• COCP/progesterone
• May
increase
dose
to
BD
10th
then
taper
• Follow
up
with
iron
supplementaDon

28. Combined
hormonal
contracepDve
• OCP-­‐cyclic/
conDnuous-­‐
adolescents
prefer
extended
cycles
• Transdermal
patch
• Vaginal
ring

29. COC
• Oral
contracepDve
pills
taper
using
monophasic
pills
can
also
be
given
• 4
pills
evenly
spaced
per
day
for
4
days
• 3
pills
per
day
for
3
days
• 2
pills
per
day
for
2
day
• And
1
pill
per
day
for
2
months
without
taking
the
placebo
pill.

30. ProgesDn
therapy
n Oral-­‐
-­‐
Primolute
N-­‐effecDve
but
poorly
tolerated
-­‐
Deviry-­‐cyclical
t/t
for
hyperplasia
n Long
acDng
injectables-­‐DMPA/NET-­‐EN
n Subcutaneous
progesDns-­‐
Etonogestrel
implant
-­‐
impact
on
bone
density
-­‐
Irreg
bleeding
and
ameno
-­‐
Possibility
of
weight
gain

31. Norethisterone
acetate
(NETA)-­‐
Dosing
Regimens
• Different
dosing
regiments
are
in
pracDce
• NETA
5-­‐10
mg,
generally
administrated
in
luteal
phase
from
day
15/19
to
day
26
in
anovulatory
cycles
• Recently
an
increase
in
the
duraDon
and
doses
has
been
invesDgated
in
paDents
with
ovulatory
dysfuncDonal
uterine
bleeding

33. SmarDnor
CR
(Norethisterone
acetate
controlled
release
micronized
tablets)
in
puberty
menorrhagia
• Norethisterone
acetate
controls
bleeding
and
normaliszes
menstrual
cycle
by
the
following
acDons'
u
Effects
on
uterus:
¡ Binds
to
progesteron
receptors
in
the
endometrium
and
brings
synchronous
secretory
changes
in
estrogen
primed
endometrium
¡
promotes
regrowth
of
endometrium
over
irregularly
denuded
surfaces
due
to
its
weak
estrogenic
acDon

34. SmarDnor
CR
(Norethisterone
acetate
controlled
release
micronized
tablets)
in
puberty
menorrhagia
u
StypDc
effect
on
uterine
hemorrhage:
¡
Checks
bleeding
by
constricDon
of
uterine
blood
vessels
(like
a
hemostaDc
agent)
¡
Used
for
the
management
of
acute
bleeding
as
well
as
for
the
prevenDon
of
recurrence.
¡
Beneficial
in
both
ovulatory
and
anovulatory
DUB.

35. Progesterones
• progesterone
alone
are
generally
effecDve
but
can
be
used
in
combinaDon
with
estrogen
• progesterone
can
be
used
cyclically
into
different
treatment
protocols:
-­‐
as
a
short
course
during
the
luteal
phase
and
relaDvely
longer
course
lasDng
21
days
from
day
5
of
the
cycle.

36. Progesterones
• Heavy
bleeding
can
be
treated
with:
1. Oral
medroxyprogesterone
10
mg
three
Dmes/day
for
14
days.
2. Medroxyprogesterone
acetate
injecDon
(Depo
Provera)
150
mg
intramuscularly
every
12
weeks.
3. Progesterone
can
also
be
used
for
medical
curenage
in
the
form
of
norethisterone
acetate
20
to
30
MG
daily
for
3
days
to
arrest
hemorrhage.
• It
may
then
be
conDnued
at
a
lower
dose
for
up
to
21
days.
withdrawal
bleeding
will
occur
on
stopping
the
treatment
that
ceases
in
4
to
5
days.

37. Side
effects
of
progesterone
only
therapy
• Need
for
long-­‐term
oral
medicaDon
and
the
possibility
of
unwanted
premenstrual
symptoms.
• Androgenic
effects
(pending
on
the
progestogen
used),
such
as
acne
and
hirsuDsm;
irregular
breakthrough
bleeding
and
change
in
carbohydrate
tolerance
and
lipid
balance.
• Depo-­‐
Proveraa
will
induced
amenorrhea
in
50%
of
users
at
1
year
and
breakthrough
bleeding
in
15
+
20%

38. Side
effects
of
progesterone
only
therapy
• The
Mirenaa
intrauterine
implant
system
(IUS)
releasing
20
mg
of
levonorgestrel/day
(LNG-­‐IUS
20)
is
a
highly
effecDve
long-­‐term
treatment
for
both
ovulatory
and
anovulatory
DUB
(Anderson
and
Rybo,
1990)
• irregular
"breakthrough"
bleeding
is
the
main
unwanted
effect
of
all
progestogen
preparaDon
and
the
main
reason
why
women
choose
to
disconDnue
these
preparaDons,
despite
their
other
advantages.

39. Moderate
Hb10
to
12
• Mostly
outpaDent
• The
treatment
typically
involves
hormonal
therapy
to
stabilize
endometrial
proliferaDon
and
shedding.
• The
choice
of
agent(s)
depends,
to
same
extent,
upon
how
heavily
the
paDent
is
bleeding.
• Girls
with
moderate
DUB
should
be
provided
with
iron
supplementaDon.
• Another
regimen
states
that
OC
pills
be
taken
3
Dmes
per
day
unDl
the
bleeding
ceases
(usually
within
48
hours),
then
tapered
to
twice
daily
for
5
days
and
then
decreased
to
once
daily
to
complete
21
days
of
hormone
therapy.

40. Severe
bleeding
hemodynamically
unstable
• Hb
<
8
gm%
/
severe
bleeding
• HospitalizaDon
• Fluid
and
blood
• Conjugated
estrogen
25
mg
IV
4-­‐6
hourly
(up
to
48
hours)
Dll
bleeding
stops
• Add
progesterone
or
COCP
• COCP
containing
30
to
35
Ug
orally
every
4
to
6
hours
Dll
bleeding
stops
and
taper
to
OD
over
10
to
14
days

41. Anovulatory
cycle
acute
bleeding
• IV
premarin
25
mg
6-­‐8
hrly
x
24-­‐48
hrs
followed
by
est
for
21
days
with
prog
added
for
10
days
for
3-­‐6
cycles
• Current
trend
is
to
give
IV
trenaxemic
acid
1
gm
with
25
mg
of
est
and
then
conDnue
with
E
and
P
as
menDoned
above

42. MulDdisciplinary
approach
• Involve
hematologist
• surgical
intervenDon
rarely
required
D
&
C,
foley
ballon
temponade
in
refractory/
life-­‐threatening
HMB

43. Role
of
Diosmin
in
Puberty
Menorrhagia
• Apart
from
hormonal
imbalance
increased
capillary
fragility
and
increased
PGE,
secreDon
can
also
be
contribuDng
causes
for
Puberty
Menorrhagia.
• LymphaDc
drainage
is
underdeveloped
in
human
endometrium.
• Increased
bleeding
causes
accumulaDon
of
debris
and
Dssue
products
which
lymphaDc
system
is
unable
to
cope.

44. Role
of
Diosmin
in
Puberty
Menorrhagia
• Vasoprotectors
like
bioflavonoid
(Diosmin)
can
play
a
vital
role
in
controlling
the
bleeding
given
along
with
hormonal
treatment,
non
hormonal
treatment.
• Diosmin
is
naturally
occurring
flavonoid
glycoside.
• Widely
used
for
more
than
40
years
worldwide
with
good
efficacy
and
safely
profile.
• In
Puberty
Menorrhagia
dose
is
900
mg
daily,unDl
the
normalisaDon
of
menstrual
cycle

46. Diosminn
in
Menorrhagia
Summary
of
Clinical
Trials
100%
pure
micronized
diosmin
is
a
potent,
gentle
non
hormonal
treatment
in
cases
of
menorrhagia,
with
or
without
hormonal
therapy
Summary
of
clinical
trials
i. Pure
diosmin
reduces
amount
of
bleeding
upto
51.9%
ii. Reduces
dura=on
of
bleeding
bi
2.6
days
iii. Relieves
dysmenorrhea
score
by
53.1
%

47. Diosminn
in
Menorrhagia
Summary
of
Clinical
Trials
iv.
Normalises
menstrual
cycle
by
82%.
v.
Effec=ve
in
func=onal
gynaecological
bleeding
in
88
to
98%
pa=ents.
vi.
Safe
and
well
tolerated
In
puberty
menorrhagia
dose
is
900
mg
daily,
unDl
the
normalizaDon
of
menstrual
cycle.

48. Follow
up
and
long-­‐term
care
• AIer
treatment
is
ini=ated,
pa=ent
should
be
seen
at
regular
intervals.
• Long-­‐term
management
depends
on
the
anaemia
and
the
desire
for
contracep=on.
• Most
experts
recommended
con=nuing
hormonal
therapy
for
at
least
6
months.
• AIer
therapy
is
discon=nued,
the
pa=ent
should
s=ll
be
followed
to
ensure
regula=on
of
mestrua=on.

49. Must
do
• All
paDents
iron
deficiency
assessed
and
treated
• No
iron
preparaDon
is
more
effecDve
than
other
• 150
to
200
mg
elemental
iron/day
in
1-­‐3
divided
doses
• Empty
stomach
with
glass
of
orange
juice
• DuraDon
of
t/t
is
3
months
beyond
normalizaDon
of
HB
to
replenish
iron
store.

50. Conclusion
• Abnormalmal
menstrual
bleeding
in
adolescents
can
be
caused
by
a
number
of
condiDons
• The
most
common
cause
is
immaturity
of
the
hypothalamic
pituitary
ovarian
axis.
• Bleeding
disorders
are
another.

51. Conclusion
• Assessment
of
each
case
with
thorough
ü
History
ü
Physical
examinaDon
and
ü
Laboratory
invesDgaDons
as
crucial
in
reaching
the
diagnosis
• Once
a
proper
diagnosis
is
made
• Counselling
of
the
paDent
and
her
parents
• Follow
up
and
long-­‐term
therapy
in
some
cases
is
required.

52. Coagulopathy
• Youngg
girls
with
blood
coagulopathy
are
at
a
high
risk
of
abnormal
bleeding
with
the
onset
of
menarche.
• Bleeding
is
usually
heavy
• Causing
anaemia
and
may
require
blood
transfusion
• Among
the
inherited
bleeding
disorders
platelet
defects
are
the
most
common
cause
of
puberty
menorrhagia

53. Mild
DUB
• Mild
uterine
bleeding
(Hgb
>
12mg/dL)
• Management
of
mild
abnormal
bleeding
consists
of
observaDon
and
reassurance.
• If
hemoglobin
(Hgb)
concentraDon
is
normal
(
>12
mg
/dL),
• Girls
with
mild
DUB
should
be
asked
to
keep
a
menstrual
calendar
and
can
be
given
the
opDon
to
avoid
treatment
with
hormonal
therapy
• They
should
follow
up
in
3
to
6
months,
unless
bleeding
becomes
more
severe,
in
which
case
they
should
be
seen
acutely.

54. When
to
admit
• HospitalizaDon
is
necessary
for
paDents
who
are
hemodynamically
unstable
• Who
have
low
Hgb
concentraDon
(<7
mg/dL),
or
• Who
have
symptomaDc
anaemia.
• Heavy
acDve
bleeding
and
Hgb
lower
than
10mg/dL
are
also
considered
by
some
to
be
an
indicaDon
for
hospitalizaDon.

55. When
to
admit
• If
the
Hgb
is
between
8
to
10
mg/dL
and
• The
paDent
is
hemodynamically
stable
• The
paDent
and
family
are
reliable
and
can
maintain
close
telephone
contact
• Home
management
may
be
possible
with
daily
monitoring

56. Acute
bleeding
• For
paDents
who
can
tolerate
oral
intake,
• Therapy
typically
includes
a
monophasic
combinaDon
OC
pill
with
50
ug
estradiol
and
0.5
mg
norgestrel
(e,
Ovral,
Ogestrel)
or
• 50
ug
estradiol
and
1
mg
norethindrone(eg,
Ovcon
50)
administrated
according
to
various
schedules.

57. Acute
bleeding
•
A
common
schedule
is
to
take
it
4
Dmes
a
day
unDl
bleeding
is
controlled.
• Then
wean
to
3
Dmes
daily
for
3
days,
and
then
to
twice
daily
to
complete
a
21
day
course
of
pills
• Then
the
paDent
starts
a
new
pack
of
pills
(
without
using
the
placebo
pills)

58. Desmonpressin
acetate
DDAVP
• Induces
secreDon
of
VWF
from
endothelial
lining
in
increased
VWF
and
F
VIII
• VWF
• Hemophilia
• PFD
• 77%
effecDve
• Side
effects-­‐
tachyphylaxis/fluid
retenDon/hyponatremia

59. Desmonpressin
for
Von
Willebrand's
Syndrome
• Desmopressin
analogue
of
arginine
vasopressin
is
given
IV
or
• Nasal
spray
1.5
mg/ml,-­‐
total
150-­‐300
mg
in
30
ml
diluted.

60. • Take
opportunity
to
educate
girl
on
lifestyle
issues
• Reassure
her
that
80%
menstrual
problems
falls
in
normal
range
• HPO
axis
immaturity
is
the
major
cause
• 10%
do
need
coagulaDon
evaluaDon

61. Summary
• Adolescents
with
gynaecological
problems
require
a
degree
of
privacy
and
• SensiDve
handling,
as
many
of
the
gynaecological
problems
• Encountered
relate
to
inDmate
body
funcDons
at
a
Dme
• When
the
individual
is
maturing
sexually
• Having
to
deal
with
issues
that
are
embarassing
and
• May
be
considered
taboo

62. Thanks