Menstrual Disorders

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83 Menstrual Disorders

Kamillah Wood, Sara B. Kinsman

Menstrual irregularity is one of the most common concerns that pediatricians address with their adolescent female patients. Being prepared to provide anticipatory guidance regarding the normal menstrual cycle will help ensure that adolescent females do not experience complications associated with dysfunctional uterine bleeding such as changes in lifestyle, anemia, hospitalization, and transfusions. When adolescent females and their caretakers are taught the risks of excessive menstrual flow, they may be more likely to call a pediatrician before an adolescent has developed a significant anemia. Teaching patients to keep a calendar of their menstrual cycles can help adolescent females to actively care for their own health and begin to communicate effectively with their providers about a number of related health topics, including dysmenorrhea, nutritional needs, and reproductive health needs.

Dysfunctional uterine bleeding (DUB) is menstrual bleeding that is not consistent with the expected timing or flow for average menstrual cycle. The normal menstrual cycle occurs every 28 days with a normal range from 21 to 35 days. Menstrual bleeding typically lasts 4 days with a normal range of 2 to 7 days. Typical blood loss is expected to be 30 mL of blood per cycle with the upper limit of normal being 80 mL per cycle. The average age for menarche in the United States is currently 12.3 years. Although anovulation is common in the first 12 to 24 months after menarche affecting approximately 50% of cycles, excessively frequent menses or high volumes of menstrual flow need to be managed carefully to avoid significant blood loss. Specifically, pediatricians can teach adolescent females and their caretakers that excess blood loss may result from when menstrual flow soaks more than six full pads or tampons per day, lasts for greater than 7 days, and occurs more frequently than every 21 days.

Eitology and Pathogenesis

The most common cause of DUB in young women is anovulation. A normal menstrual cycle starts on the first day of menstruation and begins with the follicular phase. During this phase, a developing ovarian follicle synthesizes estrogen, which promotes endometrial growth and proliferation. As estrogen levels continue to increase, estrogen provides positive feedback centrally to the pituitary gland, causing a surge in luteinizing hormone (LH) excretion. This results in release of the ovum from the follicle. The follicle forms the corpus luteum and the beginning of the luteal phase. Estrogen levels decrease, and the corpus luteum begins to produce progesterone. The progesterone promotes stabilization of the endometrial mucosa as well as glandular changes within the endometrial wall to provide an environment for implantation of a fertilized ovum. Without implantation, the corpus luteum cannot maintain production of progesterone, leading to sloughing of the endometrial lining or menstruation approximately 14 days after ovulation.

Anovulatory cycles result when the increase in estrogen during the follicular stage does not result in a surge of LH and therefore ovulation cannot occur. Because the endometrium is mainly exposed to estrogen without progesterone, it can become highly thickened, resulting in heavy, prolonged, or unsynchronized sloughing of the lining (Figure 83-1).

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Figure 83-1 Neuroendocrine regulation of menstrual cycle.

Clinical Presentation

The pediatrician should take a detailed history, including questions regarding the degree and pattern of vaginal bleeding. Asking these questions of the adolescent with the caretaker present can be helpful. Sometimes a dialogue between the adolescent and her caretaker may facilitate a fuller understanding of her bleeding pattern. Questions should include the age of menarche, the duration and amount of bleeding associated with the first few menses, the duration of menstruation subsequently, frequency, the color of menstruation, the presence of clots in the menstrual discharge, the number of pads or tampons used daily, and any need to change pads or tampons during the night. The presence of dysmenorrhea will also be helpful. Despite careful history taking, most adolescent and adult females cannot accurately account for the total amount of blood loss; however, aspects of this history will still inform the pediatrician’s laboratory evaluation.

In a confidential setting, the pediatricians should ask the adolescent directly about her sexual history, including consensual and nonconsensual sexual intercourse, history of sexually transmitted diseases, use of hormonal contraceptive methods or intrauterine devices (IUDs), and history of pregnancies or abortions. Questions of physical or sexual abuse are important, although adolescent females may need to be reminded that pediatricians are mandated reporters and will need to ensure the adolescent’s safety by reporting history of abuse to other helping adults.

The review of systems can assess for the presence of other etiologies that could cause DUB. The report of weight changes, oral lesions, or dental decay may raise concern for an eating disorder; visual changes, headaches, and galactorrhea may raise concern for a prolactinoma; acne, hirsutism, acanthosis nigricans, and obesity may raise concern for polycystic ovarian syndrome (PCOS); and nosebleeds, bruising, or petechiae may raise concern for bleeding dyscrasias.

The family history should include information regarding the history of heavy or prolonged menses, chronic anemia, bleeding disorders, PCOS, and endocrine disorders such as thyroid disease.

The pediatrician will also be interested in medication use, even those that a caretaker may not be aware of such as an oral contraceptive pill (OCP), IUD, or excessive aspirin use.

For the general physical examination, close attention to vital signs may reveal tachycardia or have orthostatic hypotension associated with severe anemia. In addition, the pediatrician should document visual field testing; thyroid enlargement; the presence or absence of galactorrhea; signs of androgen excess; and signs of extramenstrual bleeding, including bruising and petechiae.

The external genital examination can identify pubertal Tanner staging, clitoromegaly, and heavy ongoing vaginal bleeding that may be due to trauma or malodorous discharge that may be associated with a retained foreign body or anatomic abnormality. For young and nonsexually experienced adolescents, a pelvic examination may not be indicated or possible in the pediatrician’s office. If no significant concern for acute vaginal tear, foreign body, or anatomic etiology is present, the pelvic examination can be deferred.

For adolescents who are sexually active, direct observation of the source of bleeding from the vaginal mucosa or cervix may be helpful. Cervical testing for gonorrhea and chlamydia can be obtained. With a bimanual examination, the clinician can also assess the degree to which the adolescent is experiencing cervical motion tenderness, uterine tenderness, or pelvic fullness.

Laboratory evaluation should begin with a urine pregnancy test and complete blood count and differential. If there is a concern for a coagulopathy, prothrombin time, partial thromboplastin time, and a von Willebrand panel are indicated before starting hormonal treatment. Consultation with a hematologist may facilitate a comprehensive assessment of bleeding disorders. Endocrine evaluation, including thyroid-stimulating hormone, serum prolactin, free testosterone, FSH, LH, and estradiol can be helpful.

Ultrasonography is useful in adolescents who cannot undergo a full speculum examination and is indicated for adolescents who are pregnant or for whom an anatomic abnormality is suspected. Pelvic ultrasonography will be more sensitive than most pediatricians’ examination to exclude an anatomic abnormality.

Differential Diagnosis

The most common cause of DUB in adolescents during the 2 years after menarche is anovulatory cycles, but before making this diagnosis, other causes of DUB must be excluded. Foremost, pregnancy, ectopic pregnancy, and pregnancy-related complications must be excluded. Threatened, spontaneous, or incomplete abortions can cause DUB.

Blood dyscrasias are also a major cause of DUB. In one study, almost 20% of patients with complications of DUB had von Willebrand disease. Adolescents with these disorders frequently report excessive or prolonged menstrual bleeding starting at the time of menarche. Other bleeding disorders, including leukemias or lymphomas, may present with changes in uterine bleeding.

Infections with Neisseria gonorrhoeae and Chlamydia trachomatis may cause an inflammation of the endometrium or endometritis, resulting in prolonged menstrual bleeding and cervical friability. In developing countries, endometrial infiltration with tuberculosis is an important cause of DUB.

Endocrinopathies, including hypothyroidism and hyperthyroidism, prolactinomas, late-onset 21-hydroxylase deficiency, Cushing’s disease, Addison’s disease, and PCOS, can result in DUB. Disorders that affect the hypothalamic–pituitary–ovarian axis, including bulimia nervosa, are also a consideration.

Medications that impact the ovulatory cycle, such as tricyclic antidepressants, valproic acid, and antipsychotics, may be causative. Other medications that affect coagulation, such as aspirin-containing compounds, can exacerbate bleeding.

Trauma to the vagina or cervix, retained foreign body, and vascular or anatomic lesions must be included in the differential diagnosis. Congenital anatomic abnormalities may be considered when the patient reports having regular, red-colored menstrual bleeding followed by brown or prune-colored discharge between cycles. This is caused by the normal uterus emptying in a cyclic pattern while the obstructed uterus or vagina empties into a fistula slowly over a period of time. A foul smell may accompany this intermenstrual discharge because of infection with anaerobic bacteria (Figure 83-2).

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Figure 83-2 Dysfunctional uterine bleeding.

Treatment

The treatment for DUB is determined by the severity of symptoms, the underlying etiology, and complicating comorbidities. A treatment plan should be developed that stops active bleeding and prevents recurrence.

In adolescents with DUB that is not associated with significant anemia, the best approach is to provide anticipatory guidance regarding normal parameters, asking patients to keep a menstrual calendar, and periodic visits to check hemoglobin if bleeding exceeds normal expectations. A diet high in iron or adding a multivitamin with iron may be initiated as a preventive measure against anemia.

Combined hormonal contraception, such as an OCP that includes estrogen and progesterone, can be used to treat an adolescent with DUB that affects the adolescent’s daily activities or results in anemia. The rationale for using OCPs is that the estrogen component will help to stop blood loss at the actively bleeding sites within the endometrium. Estrogen also increases platelet aggregation and levels of fibrinogen, as well as factors V and IX. The progesterone component adds stabilization to the endometrium and decreases the risk of endometrial sloughing. If an adolescent has an underlying condition that does not allow for use of estrogen (i.e., a clotting disorder), therapy with progesterone only can be substituted. However, progesterone only therapy is considered less effective. An OCP with 30 µg of ethinyl estradiol is generally recommended in the combined therapy.

An adolescent with DUB and mild anemia who is not actively bleeding may be started on OCPs once daily. When active bleeding is present, the pediatrician may prescribe one pill every 6 hours until 24 hours after menses stops followed by a slow taper (i.e., one pill three times a day for 3 days, one pill twice daily for 2 days, and then one pill daily). The estrogen component of the pill may cause nausea, so an antiemetic medication may be prescribed. Bleeding usually subsides within the first 48 hours of treatment; however, if bleeding persists beyond this time frame, a higher dose of OCP may be indicated, and reevaluation of the cause of the DUB should be considered. If bleeding occurs during the hormonal taper, the medication dose should be readjusted to control bleeding. To ensure that the adolescent has time to replete iron stores, continuous hormonal therapy should be maintained for several weeks (8-12 weeks) without use of the placebo OCP. The patient and the caretaker need to be aware that the first withdrawal bleed after using OCP may be unusually heavy. OCPs can be continued for 6 months or more to give the adolescent female time to mature and increase the likelihood that her neuroendocrine system will be able to synchronize ovulatory menstrual cycles. In addition, if an adolescent is sexually active, she may choose to stay on an OCP for a longer period.

Significant anemia (hemoglobin <8 g/dL) with hemodynamic instability merits inpatient admission. Although an OCP can be used in the acute setting with dosages of estrogen at 30 µg every 4 hours, conjugated intravenous estrogen doses of 25 mg every 4 to 6 hours will usually stop the bleeding within 24 hours. If bleeding does not subside, gynecologic consultation should occur to assess the need for dilatation and curettage. Blood transfusion is indicated for adolescents who have severe anemia and are hemodynamically unstable.

Treatment of DUB related to other chronic conditions will require treatment specific to the underlying cause.

Conclusion

The pediatrician plays an important role in educating adolescent females about normative menstrual cycles and the risks associated with excess bleeding. Learning how to quickly assess DUB in the office will reduce the need for increased levels of care for a problem that can easily and comfortably be managed in the office setting. An added positive experience for pediatricians and adolescent patients is the benefit of beginning a dialogue about general and reproductive health needs.

Suggested Readings

El-Hemaidi I, Gharaibeh A, Shehata H. Menorrhagia and bleeding disorders. Curr Opin Obstet Gynecol. 2007;19(6):513-520.

Emans SJ. Dysfunctional uterine bleeding. In: Emans SJ, Laufer MR, Goldstein DP, editors. Pediatric and Adolescent Gynecology. ed 5. Philadelphia, Lippincott: Williams & Wilkins; 2005:270-286.

Lavin C. Dysfunctional uterine bleeding in adolescents. Curr Opin Pediatr. 1996;8(4):328-332.

Lazovic G, Radivojec U, Milicevic S, et al. The most frequent hormone dysfunctions in juvenile bleeding. Int J Fertil Womens Med. 2007;52(1):35-40.

Messinis IE. From menarche to regular menstruation: endocrinological background. Ann N Y Acad Sci. 2006;1092:49-56.

Rimza ME. Dysfunctional uterine bleeding. Pediatr Rev. 2002;23:227-232.

Toth M, Patton DL, Esquenazi B, et al. Association between Chlamydia trachomatis and abnormal bleeding. Am J Reprod Immunol. 2007;57(5):361-366.

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