Abnormal uterine bleeding in adolescents☆

The menstrual cycle

The menstrual cycle represents a complex interrelationship of hormones and physiologic events in the brain, the ovary, and the uterus that prepares the body for the possibility of conception. An understanding of these relationships is essential for any discourse on its irregularities.

The average menstrual cycle lasts 28 days. During this time, key changes occur in the ovary and uterus that will facilitate either implantation of a fertilized ovum or sloughing of the endometrium. These events

Adolescent menstruation

Although the onset of menstrual bleeding is recognized as a pubertal milestone, the hypothalamic–pituitary–ovarian-axis continues to mature after menarche through the first 5 years of the menstrual cycle. Near the time of menarche, the positive feedback influence of estradiol is absent and thus ovulation does not occur [8]. Lemarchand-Beraud et al [9] investigated 90 healthy girls over the first 5 years after menarche [9]. They found that estrogen, progesterone, LH, and FSH values were all

Differential diagnosis

In adolescents, as with any woman of reproductive age, the possibility of a complication of pregnancy must be initially excluded as a cause of abnormal uterine bleeding. Although the adolescent birth rate is declining in this country, more than 900,000 American teens become pregnant each year; the majority of these pregnancies is unplanned [14]. Teens may be reluctant to admit to the possibility of pregnancy, even with private questioning, so a high degree of suspicion is indicated among all

Clinical evaluation

Many adolescents are anxious about the gynecological evaluation for abnormal bleeding and may approach their visit with a great deal of apprehension. It is important to realize the complete evaluation of adolescents takes patience and an orientation toward their special needs and concerns. It is helpful to establish a relaxed atmosphere that is respectful of their privacy and emerging autonomy. Boundaries of confidentiality should be discussed at the onset of the visit and the adolescent and

Treatment

Treatment goals for adolescents with abnormal bleeding are to identify the source of the bleeding and direct therapy towards the cause, to stop abnormal bleeding, and to help the adolescent have more predictable, manageable menstrual cycles. Immediate treatment strategies can be categorized based on the severity of bleeding (Box 3). If the adolescent is bleeding profusely, is hypovolemic, or has a hemoglobin less than 9gm/dl hospitalization and immediate resuscitation with volume expansion and

Prognosis

Irregular, unpredictable, or heavy bleeding in adolescents usually occurrs as a result of a lack of full maturation of the HPO axis. Over the first 3 to 5 postmenarchal years, most patients will develop regular, cyclic menses. Southam and Richart [34] found that if normal menses had not developed within 4 years of menarche, the chance for normal menstrual function was low. Many of these women had decreased reproductive potential, endometrial cancer, and subsequent gynecologic surgeries that

Summary

Abnormal and irregular bleeding are extremely common in the adolescent period and can be looked upon as a part of normal reproductive development. It is essential to have a firm grasp on the normal, physiologic development of the menstrual cycle. Prompt recognition and treatment of the situations that may indicate underlying disorders or diseases is possible. It is important to recognize the distinct needs, goals, and developmental stages of adolescent patients. No single therapy or approach is