1
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Hall EM, Ravelo AE, Aronoff SC, Del Vecchio MT. Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females. BMC Womens Health 2024; 24:136. [PMID: 38378571 PMCID: PMC10880246 DOI: 10.1186/s12905-024-02921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding. METHODS A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. RESULTS Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin. CONCLUSIONS The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.
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Affiliation(s)
- Erin M Hall
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ana E Ravelo
- Department of Pediatrics, Brown University, Providence, RI, USA
| | - Stephen C Aronoff
- Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Michael T Del Vecchio
- Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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2
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Rosen MW, Compton SD, Weyand AC, Quint EH. The Utility of Pelvic Ultrasounds in Adolescents Presenting to the Emergency Department with Abnormal Uterine Bleeding. J Pediatr Adolesc Gynecol 2023; 36:455-458. [PMID: 37182811 DOI: 10.1016/j.jpag.2023.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
STUDY OBJECTIVE To analyze what factors influence a provider's decision to order a pelvic ultrasound (PUS) in the emergency department (ED) for adolescents with abnormal uterine bleeding (AUB), to determine if endometrial stripe (EMS) measurements are used in treatment decisions, and to evaluate if treatment outcomes differ based on EMS thicknesses. METHODS Retrospective chart review of patients aged 11-19 presenting to the ED with AUB from 2006 to 2018. Those receiving a PUS were divided into three EMS groups: ≤5 mm, 6-9 mm, and ≥10 mm. Outcomes were evaluated in admitted patients by progress notes indicating resolution of bleeding. Cross-tab, χ2, and logistic and linear regression analysis were performed. RESULTS Of 258 adolescents meeting study criteria, 113 (43.8%) had a PUS. None had an abnormality. A PUS was more likely to be performed in patients with lower hemoglobin values (P < .003). Provider decision to order a PUS did not differ by age or bleeding duration (P > .1). Among those with a PUS, 67 (59%) received hormonal therapy (pill, progestin-only, IV estrogen). There were no significant differences in treatment choices based on EMS (P < .061) or, among the 44 admitted patients (17%), in the time it took bleeding to stop after initiating treatment (pill: P = .227, progestin-only: P = .211, IV estrogen: P = .229). CONCLUSION In adolescents with AUB in the ED, performing a PUS was more common in those with low hemoglobin. EMS thickness did not appear to affect treatment decisions or inpatient outcomes. Larger studies are needed to confirm the current findings and determine if PUS is needed in the evaluation of AUB.
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Affiliation(s)
- Monica W Rosen
- Department of Obstetrics & Gynecology, Michigan Medicine, Ann Arbor, Michigan.
| | - Sarah D Compton
- Department of Obstetrics & Gynecology, Michigan Medicine, Ann Arbor, Michigan
| | - Angela C Weyand
- Department of Pediatric Hematology, Michigan Medicine, Ann Arbor, Michigan
| | - Elisabeth H Quint
- Department of Obstetrics & Gynecology, Michigan Medicine, Ann Arbor, Michigan
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3
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2023; 288:90-107. [PMID: 37499278 DOI: 10.1016/j.ejogrb.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.
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Affiliation(s)
- J L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1 avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165 chemin du Grand Revoyet, 69495 Pierre-Benite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital europeen Georges-Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hotel Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40 avenue Serge Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371 avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
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Grubman J, Hawkins M, Whetstone S, Autry M, Lazar A, Sawaya GF, Jacoby V. Emergency department visits and emergency-to-inpatient admissions for abnormal uterine bleeding in the USA nationwide. Emerg Med J 2023; 40:326-332. [PMID: 36323495 DOI: 10.1136/emermed-2021-211878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/19/2022] [Indexed: 04/23/2023]
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) is a common but understudied gynaecological problem, and data are lacking on emergency department (ED) visits and associated ED-to-inpatient admissions for AUB. This project aims to further understanding of the burden of AUB on patients and the healthcare system by establishing the number and characteristics of women with AUB in the ED and evaluating predictors of AUB-related inpatient hospitalisation in the USA. METHODS This is a cross-sectional study of women presenting to the ED with non-malignant AUB in the 2016 US Nationwide Emergency Department Sample (NEDS). Clinical, demographic and hospital system factors were evaluated. χ2 and Mann-Whitney tests were used to compare the proportion of visits with each characteristic, resulting in inpatient admission versus discharge from the ED. Multivariable logistic regression models were used to analyse predictors of AUB in the ED and of AUB-related hospitalisations. RESULTS There were 1.03 million AUB-related visits in the 2016 NEDS, of which 11.2% resulted in inpatient admission. Clinical as well as demographic and hospital system factors influenced ED disposition. Women with AUB tended to be of reproductive age, be underinsured, live in lower income and urban areas, and present to urban and public hospitals. However, older age, higher income, better insurance, presentation to private hospitals and rural residence predicted inpatient admission. CONCLUSIONS Our study highlights the ED as an essential place of care for women with AUB while also demonstrating the importance of access to outpatient gynaecology services as some AUB-related ED visits may be preventable with outpatient care. The significant demographic and hospital system differences, as well as expected clinical differences, between women with AUB admitted to inpatient and women discharged from the ED imply structural biases impacting AUB-related ED care and add to the deepening understanding of health disparities.
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Affiliation(s)
- Jessica Grubman
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
- Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mitzi Hawkins
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Sara Whetstone
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Meg Autry
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Ann Lazar
- Department of Epidemiology and Biostatistics, Universitty of California, San Francisco, San Francisco, California, USA
| | - George F Sawaya
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Vanessa Jacoby
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
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5
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El Sokkary HH, Farahat AAE. Studying Doppler Ultrasound Indices of Uterine Artery in Cases of Endometrial Cancer in Al Shatby University Hospital Patients. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2023. [DOI: 10.1007/s40944-022-00689-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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6
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Amos LE, Sherman AK, Carpenter SL. Diagnosis of Bleeding Disorders in Adolescents Hospitalized for Heavy Menstrual Bleeding. TH OPEN 2022; 6:e267-e275. [PMID: 36299809 PMCID: PMC9512591 DOI: 10.1055/a-1892-1987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Background
There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer.
Objectives
This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events.
Patients/Methods
Consecutive patients with cancer-related PE (March 1, 2006–October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE.
Results
Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%;
p
= 0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%;
p
= 0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%;
p
< 0.001) and interventricular septum displacement (53 vs. 20%;
p
< 0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE.
Conclusion
Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.
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Affiliation(s)
- Lauren E. Amos
- Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospital, Kansas City, Missouri, United States
- Department of Pediatrics, The University of Missouri-Kansas City, Kansas City, Missouri, United States
| | - Ashley K. Sherman
- Department of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shannon L. Carpenter
- Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospital, Kansas City, Missouri, United States
- Department of Pediatrics, The University of Missouri-Kansas City, Kansas City, Missouri, United States
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7
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. [Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:345-373. [PMID: 35248756 DOI: 10.1016/j.gofs.2022.02.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.
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Affiliation(s)
- J-L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4, rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hôtel-Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40, avenue Serge-Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
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8
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Bourguignon A, Tasneem S, Hayward CP. Screening and diagnosis of inherited platelet disorders. Crit Rev Clin Lab Sci 2022; 59:405-444. [PMID: 35341454 DOI: 10.1080/10408363.2022.2049199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Inherited platelet disorders are important conditions that often manifest with bleeding. These disorders have heterogeneous underlying pathologies. Some are syndromic disorders with non-blood phenotypic features, and others are associated with an increased predisposition to developing myelodysplasia and leukemia. Platelet disorders can present with thrombocytopenia, defects in platelet function, or both. As the underlying pathogenesis of inherited thrombocytopenias and platelet function disorders are quite diverse, their evaluation requires a thorough clinical assessment and specialized diagnostic tests, that often challenge diagnostic laboratories. At present, many of the commonly encountered, non-syndromic platelet disorders do not have a defined molecular cause. Nonetheless, significant progress has been made over the past few decades to improve the diagnostic evaluation of inherited platelet disorders, from the assessment of the bleeding history to improved standardization of light transmission aggregometry, which remains a "gold standard" test of platelet function. Some platelet disorder test findings are highly predictive of a bleeding disorder and some show association to symptoms of prolonged bleeding, surgical bleeding, and wound healing problems. Multiple assays can be required to diagnose common and rare platelet disorders, each requiring control of preanalytical, analytical, and post-analytical variables. The laboratory investigations of platelet disorders include evaluations of platelet counts, size, and morphology by light microscopy; assessments for aggregation defects; tests for dense granule deficiency; analyses of granule constituents and their release; platelet protein analysis by immunofluorescent staining or flow cytometry; tests of platelet procoagulant function; evaluations of platelet ultrastructure; high-throughput sequencing and other molecular diagnostic tests. The focus of this article is to review current methods for the diagnostic assessment of platelet function, with a focus on contemporary, best diagnostic laboratory practices, and relationships between clinical and laboratory findings.
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Affiliation(s)
- Alex Bourguignon
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Subia Tasneem
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Catherine P Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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9
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O'Flynn O'Brien KL, Wheeler AP, Borzutzky C, Haley KM, Kouides P, Adeyemi-Fowode O. Provider Attitudes and Practices Regarding Intrauterine System (IUS) Insertion in Adolescents With and Without Bleeding Disorders for Management of Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2021; 34:514-521. [PMID: 33497749 DOI: 10.1016/j.jpag.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/21/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE Heavy menstrual bleeding (HMB) may be the sentinel event for identifying a patient with a bleeding disorder (BD). The levonorgestrel intrauterine system (LNG IUS) has been proposed as a treatment for HMB in adolescents with and without BDs; however, no standard protocols for LNG IUS insertion in these populations exist. Providers were surveyed regarding the use of the LNG IUS in adolescents with HMB, with and without BD. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: An institutional review board-approved survey assessing provider attitudes, LNG IUS insertion practices, and patient outcomes in adolescents with HMB, with and without BD, was electronically distributed to 3523 providers in the fields of hematology, adolescent medicine, and obstetrics and gynecology. Descriptive analysis was performed. RESULTS A total of 312 respondents across all 3 specialties completed the survey. Nearly 100% of respondents considered the LNG IUS safe and effective treatment for adolescents with HMB, both with and without BD. Additionally, 66% of providers chose LNG IUS as the ideal treatment for HMB in patients with BD. Differences were noted in clinical setting for LNG IUS insertion, peri-procedural medication use, and post-procedure follow-up among specialties. Providers across all specialties reported low complication rates related to IUS insertion and use in both patient groups. CONCLUSION Providers considered the LNG IUS safe and effective treatment for HMB in adolescents with and without a diagnosed BD. Practice patterns regarding LNG IUS insertion in this population vary. Further research is necessary to explore IUS outcomes in adolescent patients with HMB, with and without BD, and to inform evidence-based protocols for LNG IUS insertion.
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Affiliation(s)
- Katherine L O'Flynn O'Brien
- Department of Pediatric and Adolescent Gynecology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.
| | - Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Borzutzky
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles/Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Kristina M Haley
- Division of Hematology and Oncology, Oregon Health and Science University, Portland, Oregon
| | - Peter Kouides
- Mary M. Gooley Hemophilia Treatment Center, Rochester Regional Health, Rochester, New York
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10
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Singer MR, Sood N, Rapoport E, Gim H, Adesman A, Milanaik R. Pediatricians' knowledge, attitudes and practices surrounding menstruation and feminine products. Int J Adolesc Med Health 2020; 34:/j/ijamh.ahead-of-print/ijamh-2019-0179/ijamh-2019-0179.xml. [PMID: 32160158 DOI: 10.1515/ijamh-2019-0179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/17/2019] [Indexed: 11/15/2022]
Abstract
Objective This study investigates whether primary care pediatricians adhere to the American Academy of Pediatrics (AAP) recommendations by routinely evaluating patients' menstrual cycles and educating patients about menstruation and feminine products. Additionally, this study examines pediatricians' knowledge and attitudes surrounding menstrual health topics. Methods A 53-item online questionnaire was developed to evaluate pediatricians' knowledge, attitudes and clinical practices regarding menstruation-related topics. The questionnaire was emailed to 2500 AAP members using a geographically-stratified sampling approach, with pediatricians in each state selected randomly. Mann-Whitney U tests, t-tests, and logistic regressions were used to assess associations between correlates and pediatricians' knowledge, attitudes and practices. Results Five hundred and eighteen out of 2500 pediatricians participated (response rate = 20.7%), 462 met inclusion criteria; 78.8% were female, 79.2% were Caucasian. The majority of the pediatricians (58.2%) were "not at all" or only "slightly" familiar with the AAP guidelines on anticipatory guidance surrounding menarche. Many reported they do not routinely provide anticipatory guidance regarding menstruation to pre-menarchal patients (24.7%), discuss menstruation with post-menarchal patients (33.1%) or ask patients the date of their last period (28.4%). The majority were unlikely to discuss feminine products with patients. Gaps in menstruation-related knowledge were noted. Male pediatricians were significantly less likely to evaluate patients' menstrual cycles and provide patient-education regarding menstruation-related topics, and had significantly lower self-rated and measured knowledge of these topics. Conclusions A concerning number of pediatricians in a national sample do not abide by AAP recommendations surrounding menstruation and exhibit knowledge gaps in this area. To effectively address the health needs of female patients, pediatricians should better incorporate menstrual health care into their clinical practice.
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Affiliation(s)
- Miriam R Singer
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, NY, USA
| | - Nikita Sood
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, NY, USA
| | - Eli Rapoport
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, NY, USA
| | - Haelynn Gim
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, NY, USA
| | - Andrew Adesman
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Ruth Milanaik
- Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, 1983 Marcus Avenue, Suite 130, Lake Success, NY11042,USA, Phone: +516-802-6100, Fax: +516-802-6131
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11
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Sidonio RF, Zia A, Fallaize D. Potential Undiagnosed VWD Or Other Mucocutaneous Bleeding Disorder Cases Estimated From Private Medical Insurance Claims. J Blood Med 2020; 11:1-11. [PMID: 32021526 PMCID: PMC6954081 DOI: 10.2147/jbm.s224683] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/25/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Von Willebrand disease (VWD) is a common inherited bleeding disorder, but awareness among health care professionals is low. We estimated the number of cases of undiagnosed VWD or other mucocutaneous bleeding disorders among commercially insured patients in the United States with a recent history of bleeding events. Methods Patients with a VWD diagnosis who were users of or candidates for von Willebrand factor replacement were identified from the IMS PharMetrics Plus Database (2006–2015). We constructed a unary patient-finding model based on 12 prediagnosis variables that best defined this population, and applied this to undiagnosed patients with recent bleeding events from the same database. Cases of symptomatic undiagnosed VWD or other mucocutaneous bleeding disorders in the commercially insured population were estimated from the “best fit” (positive predictive value [PPV] 83%) and “good fit” (PPV 75%) patients thus identified. Results Overall, 507,668 undiagnosed patients with recent bleeding events were identified (86% female, 14% male). Application of the VWD model identified 3318 best-fit and 37,163 good-fit patients; 91% of best-fit patients were females aged <46 years, with heavy menstrual bleeding as the most common claim. Projection to the full commercially insured US population suggested that 35,000–387,000 patients may have symptomatic, undiagnosed VWD or other mucocutaneous bleeding disorders. Discussion Computer modeling suggests there may be a significant number of patients with symptomatic, undiagnosed VWD or other mucocutaneous bleeding disorder in the commercially insured population. Enhanced awareness of VWD symptoms and their impact, and of screening and testing procedures, may improve the diagnosis of VWD and reduce disease burden.
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Affiliation(s)
- Robert F Sidonio
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Ayesha Zia
- Division of Hematology Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dana Fallaize
- Department of Life Sciences, Charles River Associates, Boston, MA, USA
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12
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Zia A, Jain S, Kouides P, Zhang S, Gao A, Salas N, Lau M, Wilson E, DeSimone N, Sarode R. Bleeding disorders in adolescents with heavy menstrual bleeding in a multicenter prospective US cohort. Haematologica 2019; 105:1969-1976. [PMID: 31624107 PMCID: PMC7327636 DOI: 10.3324/haematol.2019.225656] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Heavy menstrual bleeding is common in adolescents. The frequency and predictors of bleeding disorders in adolescents, especially with anovulatory bleeding, are unknown. Adolescents referred for heavy menstrual bleeding underwent an evaluation of menstrual bleeding patterns, and bleeding disorders determined a priori. The primary outcome was the diagnosis of a bleeding disorder. Two groups were compared: anovulatory and ovulatory bleeding. Multivariable logistic regression analysis of baseline characteristics and predictors was performed. Kaplan Meier curves were constructed for the time from the first bleed to bleeding disorder diagnosis. In 200 adolescents, a bleeding disorder was diagnosed in 33% (n=67): low von Willebrand factor levels in 16%, von Willebrand disease in 11%, and qualitative platelet dysfunction in 4.5%. The prevalence of bleeding disorder was similar between ovulatory and anovulatory groups (31% vs. 36%; P=0.45). Predictors of bleeding disorder included: younger age at first bleed (OR: 0.83; 95%CI: 0.73, 0.96), Hispanic ethnicity (OR: 2.48; 95%CI: 1.13, 5.05), non-presentation to emergency department for heavy bleeding (OR: 0.14; 95%CI: 0.05, 0.38), and International Society on Thrombosis and Haemostasis (ISTH) Bleeding Assessment Tool score ≥4 (OR: 8.27; 95%CI: 2.60, 26.44). Time from onset of the first bleed to diagnosis was two years in the anovulatory, and six years in the ovulatory cohort (log-rank test, P<0.001). There is a high prevalence of bleeding disorders in adolescents with heavy periods, irrespective of the bleeding pattern. Among bleeding disorders, the prevalence of qualitative platelet dysfunction is lower than previously reported.
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Affiliation(s)
- Ayesha Zia
- The University of Texas Southwestern Medical Center, Dallas, TX .,Department of Pediatrics, Children's Medical Center, Dallas, TX.,Division of Hematology/Oncology, Children's Medical Center, Dallas, TX.,Children's Medical Center, Dallas, TX
| | - Shilpa Jain
- Hemophilia Center of Western New York, John R. Oishei Children's Hospital of Buffalo, Division of Pediatric Hematology-Oncology, Buffalo, NJ
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, MN
| | - Song Zhang
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Ang Gao
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - May Lau
- The University of Texas Southwestern Medical Center, Dallas, TX.,Division of Hematology/Oncology, Children's Medical Center, Dallas, TX.,Division of Adolescent Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Ellen Wilson
- The University of Texas Southwestern Medical Center, Dallas, TX.,Children's Medical Center, Dallas, TX.,Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicole DeSimone
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Sarode
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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13
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Bumbuliene Z, Sragyte D, Klimasenko J, Bumbul-Mazurek E. Abnormal uterine bleeding in adolescents: ultrasound evaluation of uterine volume. Gynecol Endocrinol 2019; 35:356-359. [PMID: 30480465 DOI: 10.1080/09513590.2018.1538345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To evaluate ultrasonographic measurements of internal genitalia in girls suffering from abnormal uterine bleeding (AUB) and to compare the appearances with those of healthy girls. DESIGN Prospective case - control study. METHODS One hundred and five not sexually active adolescent girls were enrolled - 67 patients were suffering from AUB and there were 38 healthy peers. The groups did not differ in chronological age, or in postmenarcheal age. All girls underwent assessment of their history, clinical data and transabdominal pelvic ultrasound to evaluate their uterus and ovaries. In order to avoid the impact of endometrium cycle fluctuations, the uterine volume was calculated including and excluding its thickness. RESULTS The uterine volume among the girls suffering from AUB was significantly larger than in the control group. The mean uterine volume including endometrium in the study and control groups was 63.2 ± 24.8 and 47.8 ± 17.5 cm3, respectively (p=.001), and excluding the endometrium was 34.7 ± 13.1 and 29.1 ± 13.8 cm3 (p=.043). We did not find any significant difference in ovarian volume between the groups. CONCLUSIONS The girls in the AUB group have significantly larger uterine volume than healthy girls. This finding does not depend on endometrial thickness.
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Affiliation(s)
- Zana Bumbuliene
- a Clinic of Obstetrics and Gynecology , Faculty of Medicine, Institute of Clinical Medicine, Vilnius University , Vilnius , Lithuania
| | - Diana Sragyte
- a Clinic of Obstetrics and Gynecology , Faculty of Medicine, Institute of Clinical Medicine, Vilnius University , Vilnius , Lithuania
| | - Jelena Klimasenko
- a Clinic of Obstetrics and Gynecology , Faculty of Medicine, Institute of Clinical Medicine, Vilnius University , Vilnius , Lithuania
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14
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Gunn HM, Tsai MC, McRae A, Steinbeck KS. Menstrual Patterns in the First Gynecological Year: A Systematic Review. J Pediatr Adolesc Gynecol 2018; 31:557-565.e6. [PMID: 30064002 DOI: 10.1016/j.jpag.2018.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/13/2018] [Accepted: 07/22/2018] [Indexed: 01/15/2023]
Abstract
STUDY OBJECTIVE Understanding what constitutes a normal menstrual cycle during the first gynecological year (GY1) is a common concern of adolescents and clinicians. However, limited high-quality evidence exists. We aimed to summarize published literature regarding menstrual and ovulatory patterns in GY1. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Electronic databases (MEDLINE, Pre-MEDLINE, Embase, Web of Science, CINAHL, Cochrane Library) were systematically searched from database inception to 2018. Eligible studies described menstrual cycles, symptoms, or validated ovulatory data in healthy adolescents in GY1. Two authors independently screened studies, extracted data, and assessed methodological quality. RESULTS Twenty-two studies involving more than 2000 adolescents were included. Thirteen recorded menstrual cycle and/or symptom data and 14 measured ovulation. Mean cycle length ranged from 32 to 61 days and decreased throughout GY1. Mean menses length was 4.9 to 5.4 days. Frequent menstrual bleeding was reported in up to 23% of participants, infrequent menstrual bleeding in up to one-third, and "irregular menstrual bleeding" in up to 43%. Dysmenorrhea was reported by 30%-89% of participants. Prevalence of ovulatory cycles identified using luteal phase serum or salivary progesterone or urinary pregnanediol was 0 to 45% and increased throughout GY1. However, all used definitions that would be considered subovulatory in clinical practice. CONCLUSION Menstrual and ovulatory patterns in GY1 are diverse and differ from those of adults. A transitional phase of menstrual and ovulatory immaturity is common. However, ovulation, irregular cycles, and dysmenorrhea are not uncommon. As such, safe sexual practice should be advocated and prompt medical management should be accessible.
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Affiliation(s)
- Harriet Mary Gunn
- Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney Children's Hospital Network, Westmead, New South Wales, Australia; Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia; UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.
| | - Meng-Che Tsai
- Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Paediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Alexandra McRae
- Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney Children's Hospital Network, Westmead, New South Wales, Australia; Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Katharine S Steinbeck
- Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney Children's Hospital Network, Westmead, New South Wales, Australia; Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
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15
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Abstract
Abnormal uterine bleeding is common in adolescents and is thought to affect 9% to 14% of women in their reproductive years. Certain unique aspects of underlying inherited or acquired blood disorders exacerbate the "expected" hormonal imbalance at this age, thereby increasing the morbidity of the underlying problem. A multifactorial etiology demands a collaborative approach between hematologists and gynecologists or adolescent medicine physicians to effectively manage abnormal uterine bleeding in young women with blood disorders.
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Affiliation(s)
- Kathryn E Dickerson
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Neethu M Menon
- Pediatric Hematology Oncology, Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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16
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Rocheleau AD, Khader A, Ngo AT, Boehnlein C, McDavitt C, Lattimore S, Recht M, McCarty OJ, Haley KM. Pilot study of novel lab methodology and testing of platelet function in adolescent women with heavy menstrual bleeding. Pediatr Res 2018; 83:693-701. [PMID: 29166373 PMCID: PMC5902421 DOI: 10.1038/pr.2017.298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/29/2017] [Indexed: 01/02/2023]
Abstract
BackgroundApproximately 40% of adolescent women experience heavy menstrual bleeding (HMB), and 10-62% of them have an underlying bleeding disorder (BD). Diagnosing a BD remains challenging because of limitations of available clinical platelet function assays. The aim of this study was to characterize platelet function in a population of adolescent women with HMB using small-volume whole-blood assays.MethodsAnticoagulated whole blood was used to assess platelet GPIIbIIIa activation, α-granule secretion, and aggregation in response to multiple agonists. Platelet adhesion on collagen or von Willebrand Factor (VWF) under static and shear flow was also assessed.ResultsFifteen participants with HMB were included in the study, of which eight were diagnosed with a clinically identifiable BD. Platelet activation was blunted in response to calcium ionophore in participants without a BD diagnosis compared with that in all other participants. Impaired GPIIbIIIa activation was observed in response to all GPCR agonists, except adenosine diphosphate (ADP), in participants with qualitative platelet disorders. Our assays detected platelet aggregation in the majority of participants with a BD in response to ADP, collagen-related peptide (CRP), thrombin receptor activator 6 (TRAP-6), or U46619. Platelet adhesion and aggregation on collagen and VWF was decreased for participants with VWD.ConclusionParticipants with and without BD exhibited aberrant platelet function in several assays in response to select agonists.
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Affiliation(s)
- Anne D. Rocheleau
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Ayesha Khader
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Anh T.P. Ngo
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Colin Boehnlein
- The Hemophilia Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Cara McDavitt
- The Hemophilia Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Susan Lattimore
- The Hemophilia Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Michael Recht
- The Hemophilia Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
| | - Kristina M. Haley
- The Hemophilia Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon
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17
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Traditional Dry Cupping Therapy Versus Medroxyprogesterone Acetate in the Treatment of Idiopathic Menorrhagia: A Randomized Controlled Trial. IRANIAN RED CRESCENT MEDICAL JOURNAL 2018. [DOI: 10.5812/ircmj.60508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Adeyemi-Fowode OA, Santos XM, Dietrich JE, Srivaths L. Levonorgestrel-Releasing Intrauterine Device Use in Female Adolescents with Heavy Menstrual Bleeding and Bleeding Disorders: Single Institution Review. J Pediatr Adolesc Gynecol 2017; 30:479-483. [PMID: 27108228 DOI: 10.1016/j.jpag.2016.04.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/07/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE To identify complications and efficacy of the levonorgestrel-releasing intrauterine device (LNgIUD) in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD). DESIGN, SETTING, AND PARTICIPANTS A retrospective chart review of 13 postmenarchal adolescent girls with HMB/BD who underwent placement of an LNgIUD. INTERVENTIONS Placement of an LNgIUD. MAIN OUTCOME MEASURES Primary outcome was to identify complications from placement of an LNgIUD. Secondary outcome was to evaluate the efficacy of the LNgIUD in adolescents with BD. RESULTS Thirteen patients met study criteria. The mean age of diagnosis of HMB was 14.08 ± 1.75 years. BD or bleeding risk factor diagnoses included low von Willebrand (VW) activity in 5, type I VW disease in 5, type IIM VW disease in 1, low VW activity and factor 7 deficiency in 1, and acquired VW disease and factor 7 deficiency in 1. Before LNgIUD placement, other hormonal therapy (n = 13) and hemostatic therapy (antifibrinolytic agents, desmopressin acetate; n = 8) yielded poor control of HMB. The LNgIUD was placed using anesthesia with periprocedure hemostatic therapy with no complications. All patients reported significant improvement in HMB after LNgIUD placement and 60% achieved amenorrhea, with mean time to improvement of 94 ± 69 days. Mean hemoglobin and ferritin levels increased after LNgIUD placement compared with before LNgIUD placement values (P = .02, P = .0085, respectively). Use of supplemental hormonal and hemostatic agents decreased (n = 4) after LNgIUD placement. None required LNgIUD removal; 1 spontaneously expelled the LNgIUD with subsequent replacement. CONCLUSION Study results indicated the LNgIUD is an effective therapeutic option in postmenarchal adolescents with HMB due to BD/bleeding risk factor with minimal complications, high compliance rate, improvement in HMB and anemia, and no periprocedural bleeding with hemostatic management.
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Affiliation(s)
- Oluyemisi A Adeyemi-Fowode
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.
| | - Xiomara M Santos
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jennifer E Dietrich
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Srivaths
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Cancer and Hematology Centers, Houston, Texas
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19
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Heavy Menstrual Bleeding in Adolescents. J Pediatr Adolesc Gynecol 2017; 30:335-340. [PMID: 28108214 DOI: 10.1016/j.jpag.2017.01.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/14/2016] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
Heavy menstrual bleeding (HMB) is a very common gynecological condition in female adolescents and a frequent presenting complaint of those with bleeding disorders. Recommendations have been established to screen for bleeding disorders in this age group where appropriate. The purpose of this document is to impart clinical recommendations regarding HMB in adolescents. Specifically, in this article we provide a description of the epidemiology, clinical presentation, diagnostic approach, and treatment of HMB in adolescents.
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20
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The Utility of Routine Ultrasound in the Diagnosis and Management of Adolescents with Abnormal Uterine Bleeding. J Pediatr Adolesc Gynecol 2017; 30:239-242. [PMID: 27721027 DOI: 10.1016/j.jpag.2016.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Despite the fact that most cases of abnormal uterine bleeding (AUB) in adolescence are due to an immature hypothalamic-pituitary-ovarian (HPO) axis, the current approach to investigating adolescents who present with AUB often includes pelvic ultrasound to exclude rare structural causes. The aim of this study was to determine whether an ultrasound ordered for the investigation of AUB in adolescents detects any significant anatomic pathology or alters diagnosis and management. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS A retrospective chart review of 230 patients younger than 18 years of age who presented with AUB to the gynecology clinic at the Hospital for Sick Children in Toronto, Canada between January 2010 and December 2012 was completed. MAIN OUTCOME MEASURES Findings on pelvic ultrasound and any further imaging as well as management choices for these patients were examined. RESULTS Of all patients, 67.8% (156/230) had ultrasound done as part of their AUB workup. The most common diagnosis for the patients who received ultrasound examinations and the patients who did not was AUB due to an immature HPO axis. Of the patients who received an ultrasound examination, 72.4% (113/156) had normal findings; incidental findings were identified in 17.9% (28/156) and polycystic ovary syndrome morphology in 6.4% (10/156). 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 because of ultrasound findings. CONCLUSION Our results strongly suggest that pelvic ultrasound examination is not required in the initial investigation of AUB in the adolescent population because it did not alter treatment in any of our patients.
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Important considerations in adolescent health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding. Curr Opin Pediatr 2016; 28:778-785. [PMID: 27676642 DOI: 10.1097/mop.0000000000000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The present article addresses recent research related to three key facets of adolescent preventive care and health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding. RECENT FINDINGS Recent studies suggest that long-acting reversible contraception use results in significantly lower rates of unintended pregnancies, and is well tolerated by nulliparous adolescent females. Additionally, a strong recommendation from a pediatric primary care provider is extremely effective in ensuring human papillomavirus vaccination prior to sexual debut. Finally, heavy menstrual bleeding is often under-recognized in adolescents, and evaluation and treatment of these patients are variable. SUMMARY Based on the recent literature findings, the pediatric primary care provider should be encouraged to, first, recommend long-acting reversible contraception for prevention of unintended pregnancy in adolescent patients; second, strongly endorse vaccination to protect against human papillomavirus in all patients prior to sexual debut; and, third, screen adolescent females for signs and symptoms of heavy menstrual bleeding.
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Rajpurkar M, O'Brien SH, Haamid FW, Cooper DL, Gunawardena S, Chitlur M. Heavy Menstrual Bleeding as a Common Presenting Symptom of Rare Platelet Disorders: Illustrative Case Examples. J Pediatr Adolesc Gynecol 2016; 29:537-541. [PMID: 26876967 DOI: 10.1016/j.jpag.2016.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/01/2016] [Accepted: 02/04/2016] [Indexed: 11/28/2022]
Abstract
Heavy menstrual bleeding (HMB) is a common symptom in patients who present to the obstetrician-gynecologist or adolescent medicine specialist and might result from an underlying inherited bleeding disorder. Whereas relatively common bleeding disorders such as von Willebrand disease are often included in standard laboratory assessments, rarer platelet function disorders can be challenging to diagnose. Additionally, HMB can be a particularly difficult symptom to manage in adolescents with platelet function disorders, and it is associated with decreased quality of life. We review the diagnostic and management issues of patients with platelet function disorders through the presentation of 2 patient case reports, with a focus on a diagnosis of Glanzmann thrombasthenia, an inherited qualitative disorder that affects platelet function. Whereas the first patient presented to the emergency department before the diagnosis of a bleeding disorder and required a hematologic referral and extensive laboratory assessments, the second patient had been diagnosed with Glanzmann thrombasthenia as a child but experienced severe management challenges at the onset of menarche. In both patients, collaboration between the obstetrician-gynecologist or adolescent medicine specialist and the hematologist was critical for achieving acute management of the bleeding symptoms and for ensuring optimal long-term disease management. Together, these cases highlight the importance of properly identifying females with HMB who might have an undiagnosed bleeding disorder and of consulting with a hematologist to determine an appropriate management plan throughout all life stages.
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Affiliation(s)
- Madhvi Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Wayne State University and Children's Hospital of Michigan, Detroit, Michigan.
| | | | | | - David L Cooper
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc, Plainsboro, New Jersey
| | - Sriya Gunawardena
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc, Plainsboro, New Jersey
| | - Meera Chitlur
- Carman and Ann Adams Department of Pediatrics, Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
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Menstrual management and reproductive concerns in adolescent and young adult women with underlying hematologic or oncologic disease. Curr Opin Pediatr 2016; 28:421-7. [PMID: 27138999 DOI: 10.1097/mop.0000000000000359] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Heavy menstrual bleeding is common among adolescent and young adult women, and can affect health-related quality of life. The cause of heavy menstrual bleeding is not uncommonly because of an underlying hematologic or oncologic disease process, which substantially influences the way patients are counseled and treated. RECENT FINDINGS Options for menstrual management are more numerous today than ever before and range from minimizing monthly blood loss to suppressing the cycle altogether. However, an underlying bleeding disorder or malignancy can introduce many nuances and limits in individual patient care, which this review highlights. Additionally, because survival rates for adolescent and young adult cancers are improving, more of these patients are planning for lives after their disease, which may include starting or adding to a family. Options for fertility preservation during cancer therapy regimens are solidifying and both primary practitioners and subspecialists should be aware of the possibilities. SUMMARY Patients with underlying hematologic or oncologic disease require management of menstrual bleeding, but also deserve a comprehensive evaluation and counseling regarding their individualized contraceptive needs and fertility preservation options during their reproductive years. This review employs the latest evidence from current literature to help guide clinicians caring for this unique demographic.
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Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding. Thromb Res 2016; 143:91-100. [PMID: 27208978 DOI: 10.1016/j.thromres.2016.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/26/2016] [Accepted: 05/01/2016] [Indexed: 11/20/2022]
Abstract
Unpredictable, prolonged or heavy menstrual bleeding (HMB) may be expected for many adolescents soon after menarche. A decade of clinical experience and research has now established firmly that bleeding disorders (BD) are common in adolescents with HMB. Despite these advances, many questions remain, and several aspects of the diagnosis and management of BDs in adolescents are not supported by rigorous clinical trials. In this overview, four major areas will be discussed. First, we will discuss the frequency of BDs in young women with HMB. Up to 20% of older females with HMB are thought to have an underlying BD. Estimates from retrospective studies in adolescents suggest a prevalence that varies anywhere from 10 to 62%. Prospective studies with uniform hemostatic evaluation are needed to answer this question definitively. Second, we will review existing tools that help screen and diagnose adolescents with HMB with an underlying BD. Although identification of an underlying BD in older women with HMB is relatively straight forward, uncertainties remain for adolescents. Heavy menstrual bleeding in this age group may have different pathophysiological underpinnings than those in older women and may often be disregarded as anovulatory. There is an urgent need to develop novel tools, and evaluate existing diagnostic strategies in adolescents. Third, we will discuss the optimal medical management of HMB in young adolescents. As direct evidence is largely lacking, these areas are also subject to extrapolation from older women. Lastly, an important area- prediction, and management of future bleeding in those adolescents who are diagnosed with a mild BD-will be discussed. Throughout, areas of controversy and opportunities for further research are highlighted.
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ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol 2016; 126:e143-e146. [PMID: 26595586 DOI: 10.1097/aog.0000000000001215] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite variations worldwide and within the U.S. population, median age at menarche has remained relatively stable-between 12 years and 13 years-across well-nourished populations in developed countries. Environmental factors, including socioeconomic conditions, nutrition, and access to preventive health care, may influence the timing and progression of puberty. A number of medical conditions can cause abnormal uterine bleeding, characterized by unpredictable timing and variable amount of flow. Clinicians should educate girls and their caretakers (eg, parents or guardians) about what to expect of a first menstrual period and the range for normal cycle length of subsequent menses. Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood. It is important for clinicians to have an understanding of the menstrual patterns of adolescent girls, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate the adolescent girl patient. By including an evaluation of the menstrual cycle as an additional vital sign, clinicians reinforce its importance in assessing overall health status for patients and caretakers.
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Dowlut-McElroy T, Williams KB, Carpenter SL, Strickland JL. Menstrual Patterns and Treatment of Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders. J Pediatr Adolesc Gynecol 2015; 28:499-501. [PMID: 26231609 DOI: 10.1016/j.jpag.2015.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 03/03/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To characterize menstrual bleeding patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective review of female patients aged nine to 21 years with known bleeding disorders who attended a pediatric gynecology, hematology, and comprehensive hematology/gynecology clinic at a children's hospital in a metropolitan area. MAIN OUTCOME MEASURES Prevalence of heavy menstrual bleeding at menarche, prolonged menses, and irregular menses among girls with bleeding disorders and patterns of initial and subsequent treatment for heavy menstrual bleeding in girls with bleeding disorders. RESULTS Of 115 participants aged nine to 21 years with known bleeding disorders, 102 were included in the final analysis. Of the 69 postmenarcheal girls, almost half (32/69, 46.4%) noted heavy menstrual bleeding at menarche. Girls with von Willebrand disease were more likely to have menses lasting longer than seven days. Only 28% of girls had discussed a treatment plan for heavy menstrual bleeding before menarche. Hormonal therapy was most commonly used as initial treatment of heavy menstrual bleeding. Half (53%) of the girls failed initial treatment. Combination (hormonal and non-hormonal therapy) was more frequently used for subsequent treatment. CONCLUSIONS Adolescents with bleeding disorders are at risk of heavy bleeding at and after menarche. Consultation with a pediatric gynecologist and/or hematologist prior to menarche may be helpful to outline abnormal patterns of menstrual bleeding and to discuss options of treatment in the event of heavy menstrual bleeding.
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Affiliation(s)
- Tazim Dowlut-McElroy
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Karen B Williams
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Section of Hematology, Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospitals, Kansas City, Missouri
| | - Julie L Strickland
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; Section of Gynecological Surgery, Department of Surgery, Children's Mercy Hospitals, Kansas City, Missouri
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