It 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 patients complain of menstrual problems that actually fall within normal variations. In the first year after menarche, 50% of cycles are anovulatory, but 80% still fall in the normal range for duration. By the third year of menarche, 95% of menstrual cycles fall into this range. Charting 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. There are multiple causes for abnormal uterine bleeding in adolescents, the most likely cause is dysfunctional uterine bleeding (DUB) due to an immature hypothalamic-pituitary-ovarian (HPO) axis, causing an ovulatory cycles and irregular bleeding

1. Dr. Laxmi Shrikhande MD; FICOG; FICMCH;FICMU
 Director-Shrikhande Fertility Centre, Nagpur
 Senior Vice President FOGSI 2012
 Associate member RCOG, London
 Member of European Society of Human Reproduction
 Received Bharat excellence Award for contribution to women’s health
 Chairperson HIV Committee FOGSI 2009-12
 Received best FOGSI committee award
 National Editor-The Journal of OB / GY of India
 Vice Chairperson Elect Indian College of OB/GY
 Publications-Thirteen National & seven International
 Editor-FOGSI Focus on HIV in women
 Editor-FOGSI Focus on SUI- Myths & Facts
 Presented Papers at FIGO,SAFOG,AOFOG, IFFS

2. Puberty menorrhagia
Dr Laxmi Shrikhande
Director-Shrikhande Fertility Clinic

3. Abnormal Menstrual Bleeding
Pediatr Ann. 2015 Sep;44(9):e218-22

4. 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 patients complain of menstrual problems that actually fall
within normal variations. In the first year after menarche, 50% of
cycles are anovulatory, but 80% still fall in the normal range for
duration. By the third year of menarche, 95% of menstrual cycles
fall into this range.
• Charting 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
• Amenoorrohea followed by prolonged HMB-PCOS/
anovulatory cycles
• Sexual history
• Bleeding diethesis
• Medications
• Renal disease
• Liver disease
• Family H/O bleeding disorder

6. Detail menstrual history
• age at menarche
• timing, duration, and quantity of her uterine bleeding.
• cramping and/or clots
• should address psychosocial stressors,
• weight changes,
• eating and
• exercise habits,
S trickland J, Gibson EJ, Levine SB. Dysfunctional uterine bleeding in adolescents. J Pediatr
Adolesc Gynecol. 2006; 19(1):49-51.
Effective history taking from an adolescent requires particular skills
and sensitivities

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

8. Objective definition
• Prolonged –more than 7 days bleeding or
• Excess blood loss > 80 ml / menstrual cycle
• Patient comes with diagnosis..You need to find out
the cause

9. aetiology
• HPO dysfunction 50 %-anovulatory cycles-est hyperplasia
• Blood dyscrasias 20 % -coag disordes , thrombocytopenic purpura,Von
Willebrand’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 multiple causes for abnormal uterine
bleeding in adolescents, the most likely cause is
dysfunctional uterine bleeding (DUB) due to an
immature hypothalamic-pituitary-ovarian (HPO) axis,
causing anovulatory cycles and irregular bleeding
• Before the diagnosis of immature HPO axis can be
assumed, more serious disorders must be ruled out
Matytsina LA, Zoloto EV, Sinenko LV, Greydanus DE. Dysfunctional uterine bleeding in adolescents:
concepts of pathophysiology and management. Prim Care Clin. 2006; 33(2): 503-515
A COG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: management of
anovulatory bleeding. Int J Gynaecol Obstet. 2001;72(3):263-271.

11. Anovultion is the major cause
• 74.28% of cases of puberty menorrhagia were due to
anovulatory dysfunctional uterine bleeding.
• Chaudury et al reported 71%6, Roychowdhury
61.5%7, Neinstein 95%8 of cases of puberty
menorrhagia as being due to anovulation due to
immaturity of hypothalamic pituitary ovarian axis.
Chaudhury S, et el Indian medical journal 2007; 101(5); 161-64.
Roychowdhury J,et el A study to evaluate the ethiological factors and management of puberty
menorrhagia OJHAS VOL 7 Issue 1; (2008 Jan-Mar) Online journal of health and allied
sciences.
Neinstein LS Menstural problems in adolescents Med Clin North Am 1990; 74: 1181-90.
J. Med. Sci. (Peshawar, Print) January 2012, Vol. 20, No. 1: 15-18

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, subfertility and diabetes as well
as the possible risks of endometrial hyperplasia and
carcinoma (Hardiman et al., 2003) and cardiovascular
disease (recently reviewed by Rajkowha et al., 2000)
and breast cancer (Balen, 2001) require
consideration.

13. Differential Diagnosis
• Immature HPO-anovualtory cycles
– 1 yr after menarche 85 % / 4 yr after menarche 44 %
• Bleeding Diethesis
• PCOS-5-10 % endometrial hyperplasia
• Other Endocrinopathies-hypo/hyper thyroid/ cushing
• Pregnancy and related conditions-many r sexually active
• Duplication of Mullerian system
• Polyps and Fibroids
• Pelvic infections
• Medications-hormones / antidepressant/anticoagulant

14. 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 South East Asia have found platelet
function disorders as the leading inherited bleeding
disorder in women with menorrhagia
Nazli H, Nusrat hassan, Tasneem farzana, Tahir Sultan Shamsi Adolescent
menorrhagia due to platelet disorder JPMP 1/5/52011.

15. Investigation
• UPT
• CBC
• USG
• Bleeding disorder
• Thyroid function test / PRL
• PCOS tests if needed
• Pelvic USG-PCOD fibroids

16. Is USG needed in initial evaluation ??
• retrospective chart review of 230 patients <18 years old presenting with
AUB to the gynecology clinic
• The most common diagnosis in both the ultrasound group and non-
ultrasound group with AUB due to an immature HPO axis.
• Of the patients who received an ultrasound, 72.4% had normal findings,
incidental findings were identified in 17.9% and PCOS morphology in 6.4%.
• Structural causes of AUB were found in only 2 (1.3%) of the adolescents
imaged.
• No patient had a change in her AUB management plan due to ultrasound
findings.
• pelvic ultrasound is not required in the initial investigation of AUB in the
adolescent population
J Pediatr Adolesc Gynecol. 2016 Oct 6. pii: S1083-3188(16)30206-6

17. Lab work
• ACOG recommends that all patients younger than 18 who
present with abnormal uterine bleeding be screened for
coagulation disorders, particularly 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 a partial
thromboplastin time, prothrombin time, and assessment of
platelet function, plasma von Willebrand factor (VWF)
antigen, and plasma VWF activity (ristocetin cofactor activity).
ACOG Committee on Adolescent Health Care. ACOG Committee Opinion No 349,
November 2006. Menstruation in girls and adolescents: using the menstrual cycle as a vital
sign. Obstet Gynecol. 2006;108(5):1323-1328.
ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: management of
anovulatory bleeding. Int J Gynaecol Obstet. 2001;72(3):263-271.

18. Bleeding disorders
• Young girls with blood coagulopathies are at a high risk of 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
coagulation disorders.13.
• In our study 4(11.4%) patients had coagulation defects. Platelet function
defects are an important cause of menorrhagia.
• Saxena14 et al found platelet function disorder in 83% of women with
menorrhagia due to coagulation defects.
Claessens CA, Cowell CA Acute adolescent menorrhagia American journal obstet
Gynaecol 1981; 139(3); 277-80.
Saxena R, Gupta M, Gupta K, Kashyap R, Choudry VP Inherited bleeding disorder in Indian
Women with menorrhagia Haemophilia 2003; 9: 193-96.
J. Med. Sci. (Peshawar, Print) January 2012, Vol. 20, No. 1: 15-18

19. Frequently diagnosed bleeding disorders
• Von Willebrand disease
• Mild platelet function disorders
• Mild factor deficiencies-eg factor XI

20. Criteria prompting evaluation of bleeding disorders
• Personal H/O->/ 1 of the following sym
– Epistaxis-> 10 min requiring medical attention
– Spontaneous bruising > 2 cm / minor wound bleeding > 5 min
– Bleeding from oral cavity/ GIT without obvious lesiaon
– Prolonged / excessive bleeding after surgery
– Hemorrhage requiring BT
• Family H/O
– H/O bleeding disorders
– Significant bleeding complication not yet investigated
• HMB since menarche
• Hge from corpus luteum

21. Bleeding disorder investigations
• 1st
line-
– CBC/ PS/ APTT / PT / TT
– Ferritin / KFT / LFT /TSH
– VWF-Ag , VWF-Rco-ristocetin cofactor activity
• 2nd
line
– Repeat VWF Ag, VWF-Rco-F VIII
– Platelet function tests
• 3rd
line-
• Factor assays-II, V,VII, XI, XIII
• Further sub specialised tests-in consultation with hematologist

22. Mgt aim
• Contol menorrhagia
• Prevent or treat anaemia
• Prevent recurrence
• Treat the cause

23. management
Determining factors for treatment-
• Underlying etiology
• Patient’s need for contraception
• Her adherence / compliance capabilities
• Acceptability of adverse effects / costs
• There is significant overlap in the mgt of pts with and
without bleeding disorders
Management of DUB in the adolescent is medical in almost
all circumstances

24. Multiple modalities
• NSAIDS
• Antifibrinolytics
• Hormonal
• DDAVP
• Replacement of missing coagulation factor

25. 1st
line-non hormonal
• NSAIDS-ibuprofen, Naproxen, Mefenamic acid
• Antifibrinolytics-trenexamc acid / VWF / zpfd /
• First line treatment in mild cases is tranexamic acid
and NSAIDS during the menstrual cycle9.
Tranexamic acid is effective, safe, the bioavailability is
35% which requires administration of at least 1 gm 4-
6 hourly10
Royal college of obstetrician and gynecologists The initial management of
menorrhagia, RCOG evidence based clinical guidelines No. 1 London 1999.
Lethaby A, Farquhar C, Cooke l Antifibrinolytic for heavy menstrual bleeding The
Cochrane library issue 1-2003.

26. Mild DUB-hemodynamically stable
• Hb > 10 gm %
• COCP / progesterone
• May increase dose to BD and then taper
• Follow up with iron supplementation

27. Combined hormonal contraceptive
• OCP-cyclic/ continuous- adolescents prefer
extended cycles (84/ 7)
• Transdermal patch
• Vaginal ring

28. COC
• Oral contraceptive 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
days and 1 pill /per day for 2 months without taking
the placebo pill11.
Linda M, Szymanski, Kimberly B Abnormal uterine bleeding, The John Hopkins manual of
Gynecology and obstetrics Third edition page 417-428 Lippincote Williams and wilkins

29. Progestin therapy
• Oral-
– primolute N-effective but poorly tolerated
– Deviry-cyclical t/t for hyperplasia
• Long acting injectables-DMPA / NET-EN
• Subcutaneous progestins-Etonogestrel implant
– Impact on bone density
– Irreg bleeding and ameno
– Possibility of wt gain
• LNG-IUS

30. Different dosing regimens are in practice
•NETA 5-10 mg, generally administered in luteal phase from day 15/19 to day 26 in
anovulatory cycles
•Recently an increase in the duration and dosage has been investigated in patients
with ovulatory dysfunctional uterine bleeding1
•Administration of oral progestogens from day 5 to day 26 of the cycle produced a
significant reduction in bleeding1
Acute severe anovulatory bleeding:
•High dose NETA 15 mg & treatment should continued for 3 weeks, tapering the
dose after 7-10 days
Norethisterone acetate (NETA) – Dosing Regimens
Lethaby et al., The Cochrane Library 2008, Issue
1
In studies, Norethisterone progestogens were more effective in the
treatment of dysfunctional uterine bleeding than dydrogesterone. (Am. Med. J.
1 (1): 23-26, 2010)

31. Advantages of Micronized formulations of
Norethisterone acetate controlled release

32. Smartinor CR (Norethisterone acetate controlled release
micronised tablets ) in Puberty Menorrhagia
I
 Norethisterone acetate controls bleeding and normalizes menstrual cycle by
the following actions:
 Effects on Uterus:
 Binds to progesterone receptors in the endometrium and brings synchronous
secretory changes in estrogen primed endometrium
 Promotes regrowth of the endometrium over irregularly denuded surfaces due to
its weak estrogenic action
 Styptic effect on uterine hemorrhage:
 Checks bleeding by constriction of uterine blood vessels (like a hemostatic
agent)
 Used for the management of acute bleeding as well as for the prevention of
recurrence. Beneficial in both ovulatory and anovulatory DUB.

33. progesterones
• Progesterones alone are generally effective but can be used in
combination with estrogen.
• Progesterone can be used cyclically in two different treatment protocols:
as a short course during the luteal phase and a relatively longer course
lasting 21 days from day 5 of the cycle.
• Heavy bleeding can be treated with (1) oral Medroxyprogesterone 10 mg
three times /day for 14 days. (2) Medroxyprogesterone acetate injection
(Depo Provera) 150 mg intramuscularly every 12 weeks. (3) Progesterone
can also be used for medical curettage, in the form of norethisterone
acetate 20-30 mg daily for 3 days to arrest haemorrhage.
• It may then be continued at a lower dose for up to 21 days. Withdrawal
bleeding will occur on stopping the treatment that ceases in 4-5 days

34. Side effects of progesterone only therapy
• need for long-term oral medication and the possibility of unwanted `pre-
menstrual symptoms’
• androgenic effects (depending on the progestogen used), such as acne and
hirsutism; irregular breakthrough bleeding and a change in carbohydrate
tolerance and lipid balance.
• Depo-Proveraâ will induce amenorrhoea in 50% of users at 1 year and
break through bleeding in 15±20%
• The Mirenaâ intrauterine implant system (IUS) releasing 20 mg of
levonorgestrel/day (LNG-IUS 20) is a highly effective long-term treatment
for both ovulatory and anovulatory DUB (Anderson and Rybo, 1990).
• Irregular `breakthrough' bleeding is the main unwanted effect of all
progestogen preparations and the main reason why women choose to
discontinue these preparations, despite their other advantages.

35. Moderate hb 10-12
• Mostly outpatient
• The treatment typically involves hormonal therapy to stabilize
endometrial proliferation and shedding.
• The choice of agent(s) depends, to some extent, upon how heavily the
patient is bleeding.
• Girls with moderate DUB should be provided with iron supplementation.
• Another regimen states that OC pills be taken 3 times per day until 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.
•
R imsza ME. Dysfunctional uterine bleeding. Pediatr Rev. 2002;23(7):227-233.

36. Severe bleeding-hemodynamically unstable
• Hb < 8 gm % / severe bleeding
• Hospitalization
• Fluid and blood
• Conjugated estrogen 25 mg IV 4-6 hrly (upto 48 hrs)
till bledding stops
• Add progesterone or COCP
• COCP containing 30-35 Ug EE orally every 4-6 hrs
till bleeding stops and taper to OD over 10-14 days

37. Anovulatory cycles-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 continue with E and P as
mentioned above

38. Multidisciplinary approach
• Involve hematologist
• Surgical intervention rarely required-D & C, foley
ballon temponade in refractory / life threatning HMB

39. Role of Diosmin in Puberty Menorrhagia
 Apart from Hormonal imbalance increased Capillary fragility and increased
PGE 2 secretion can also be a contributing causes for Puberty menorrhagia.1
 Lymphatic drainage is underdeveloped in human endometrium. Increased
bleeding causes accumulation of debris and tissue products which lymphatic
system is unable to cope.
 Vasoprotectors like bioflavonoid (Diosmin) can play a vital role in controlling
the bleeding given along with hormonal treatment , non hormonal treatment.
 Diosmin is a naturally occurring flavonoid glycoside . Widely used for more
than 40 years worldwide with good efficacy and safety profile.
 In Puberty Menorrhagia Dose is 900 mg daily, until the normalization of
menstrual cycle.
1. International Journal of Gynecology and Obstetrics , Volume 89 , Issue 2 , 156 - 157

40. How can Diosmin be useful in Puberty
Menorrhagia
Diosmin
Micronized and 100% pure diosmin formulation should be preferred over the
conventional formulations of DIOSMIN in the market for better results .
Micronization of Diosmin increases the surface area available for intestinal
absorption, thus increases the bioavailability Diosmin.

41. Diosmin 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 duration of bleeding by 2.6 days
iii. Relieves dysmenorrhea score by 53.1%
iv. Normalizes menstrual cycle by 82%.
v. Effective in Functional gynaecological bleeding in 88-98% patients.
vi. Safe and well tolerated
In Puberty Menorrhagia Dose is 900 mg daily, until the normalization of
menstrual cycle
Source : Int J Gynaecol Obstet. 2005 May;89(2):156-7, Gobet A. Med. Prat. 1978; (1-2): 713-14

42. FOLLOW-UP AND LONG-TERM CARE
• After treatment is initiated, patients should be seen
at regular intervals
• Long-term management depends on the anemia and
the desire for contraception.
• Most experts recommend continuing hormonal
therapy for at least 6 months.
• After therapy is discontinued, the patient should still
be followed to ensure regulation of menstruation.

43. Must do
• All pts iron deficiency assessed and treated
• No iron preparation is more effective than other
• 150-200 mg elemental iron/dayin 1-3 divided doses
• Empty stomach with glass of orange juice
• Duration of t/t is 3 months beyond normalisation of
HB to replenish iron store

44. conclusion
• Abnormal menstrual bleeding in adolescents can be caused by
a number of conditions, the most common cause is
immaturity of the hypothalamic pituitary ovarian axis.
• Bleeding disorders are another.
• Assessment of each case with thorough history, physical
examination, and laboratory investigations are crucial in
reaching the diagnosis.
• Once a proper diagnosis is made, counseling of the patient
and her parents, follow up and long term therapy in some
cases is required.

45. Dr. Laxmi Shrikhande
Shrikhande IVF & Surrogacy Center
Ph-96234 59766 / shrikhandedrlaxmi@gmail.com

46. 'Spiritual blossoming' simply means
blossoming in life in all
dimensions.
Being happy, at ease with yourself
and with everybody around you.
Sri Sri Ravi Shankar
The Art of Living

47. coagulopathy
• Young 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 causes of puberty menorrhagia2
Phillipp CS, Faiz A, Dowling N, Dilley A, Micheals LA et al Age and
prevalence of bleeding disorders in women with menorrhagia Obstet
gynaecol 2005; 105: 61-68.

48. Mild DUB
• Mild Uterine Bleeding (Hgb >12 mg/dL) Management
of mild abnormal bleeding consists of observation
and reassurance. If hemoglobin (Hgb) concentration
is normal (>12 mg/dL), girls with mild DUB should
be asked to keep a menstrual calendar and can be
given the option 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.

49. When to admit
• Hospitalization is necessary for patients who are hemodynamically
unstable, who have low Hgb concentration (<7 mg/ dL), or who have
symptomatic anemia.8 E mans SJ. Dysfunctional uterine bleeding. In:
Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent
Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2005:270.
• Heavy active bleeding and Hgb lower than 10 mg/dL are also considered
by some to be an indication for hospitalization.
• If the Hgb is between 8 and 10 mg/dL, and the patient is hemodynamically
stable, and the patient and family are reliable and can maintain close
telephone contact, home management may be possible with daily
monitoring

50. Acute bleeding
• For patients who can tolerate oral intake, therapy
typically includes a monophasic combination OC pill
with 50 g estradiol and 0.5 mg norgestrel (eg,μ
Ovral, Ogestrel) or 50 g estradiol and 1 mgμ
norethindrone (eg, Ovcon 50), administered
according to various schedules. A common schedule
is to take it 4 times a day until bleeding is
controlled, then wean to 3 times daily for 3 days, and
then to twice daily to complete a 21day course of
pills.8 Then the patient starts a new pack of pills
(without using the placebo pills). For patients who

51. Desmopressin acetate DDAVP
• Induces secretion of VWF from endothelial lining in
increased VWF and F VIII
• VWF
• Hemophilia
• PFD
• 77 % effective
• Side effects-tachyphylaxis / fluid retention/
hyponatremia

52. Desmopressin for Van 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

53. • Take he opportunity to educate girl on life style
issues
• Reassure her that 80 % menstrual problems falls in
normal range
• HPO axis immaturity is the major cause
• 10 % do need coagulation evaluation

54. summary
• Adolescents with gynaecological problems require a
degree of privacy and sensitive handling, as many of
the gynaecological problems encountered relate to
intimate body functions at a time when the individual
is maturing sexually and having to deal with issues
that are embarrassing and may be considered taboo