Abnormal uterine bleeding in adolescents☆
Section snippets
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
References (34)
- et al.
Acute adolescent menorrhagia
Am J Obstet Gynecol
(1981) - et al.
Management of abnormal uterine bleeding
Am J Obstet Gynecol
(1996) - et al.
Epidemiological investigation of the prevalence of von Willebrand's disease
Blood
(1987) - et al.
Frequency of inherited bleeding disorders in women with menorrhagia
Lancet
(1998) - et al.
Bleeding disorders: a common cause of menorrhagia in adolescents
J Pediatr
(2001) - et al.
Polycystic ovary syndrome
Endocrinol Metab Clin North Am
(1997) - et al.
Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy
J Pediatr Adolesc Gynecol
(1997) - et al.
Uterine myomas in adolescents: case report and a review of the literature
J Pediatr Adolesc Gynecol
(1996) - et al.
Triphasic norgestimate-ethinyl estradiol for treating dysfunctional uterine bleeding
Obstet Gynecol
(2000) - et al.
The prognosis for adolescents with menstrual abnormalities
Am J Obstet Gynecol
(1966)
Dysfunctional uterine bleeding in adolescents
J Reprod Med
The neuroendocrine control of the menstrual cycle
Recent Prog Horm Res
Control of preovulatory follicular estrogen biosynthesis in the human ovary
J Clin Endocrinol Metab
Inhibins and activins in human ovulation, conception and pregnancy
Hum Rep Update
Characterization of the physiological pattern of episodic gonadotropin secretion throughout the human menstrual cycle
J Clin Endocrinol Metab
Morphology of haemostasis in menstrual endometrium
Br J Obstet Gynecol
Maturation of the hypothalamo-pituitary-ovarian axis in adolescent girls
J Clin Endo Metab
Cited by (34)
Chapter 16 - Evaluation of the Cyclic Endometrium and Benign Endometrial Disorders
2017, Diagnostic Gynecologic and Obstetric PathologyMenstruation in adolescents: What can we wait for?
2010, Anales de Pediatria ContinuadaDysfunctional Uterine Bleeding in Adolescent Females Associated with Endocrine Causes and Medical Conditions
2010, Journal of Pediatric and Adolescent GynecologyCitation Excerpt :If the patient is sexually active, cultures for chlamydia and gonorrhea should be obtained. If the patient is not a candidate for a pelvic exam, a transabdominal ultrasound may be performed to assess the internal organs.6,7 The laboratory assessment should be guided by the history and physical.
Menstrual Disorders in Adolescent Females: Current Concepts
2009, Disease-a-MonthEvaluation and Treatment of Menorrhagia in an Adolescent Population
2008, Journal of Minimally Invasive GynecologyAbnormal Uterine Bleeding
2007, Reproductive Endocrinology and Infertility
- ☆
This article was originally published in Infertility and Reproductive Medicine Clinics of North America 14:1, 2003.