Bleeding disorders and heavy menses in adolescents

Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist

Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting >7 days, menstrual flow which soaks >5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.

Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist

Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting >7 days, menstrual flow which soaks >5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.

Use of levonorgestrel intrauterine system for medical indications in adolescents

The levonorgestrel intrauterine system (LNG-IUS) is an underused contraceptive method in adolescent populations. In addition to being a highly effective, reversible, long-acting contraception, the LNG-IUS has many noncontraceptive health benefits including reduced menstrual bleeding, decreased dysmenorrhea and pelvic pain related to endometriosis, and menstruation suppression in teens with physical or developmental disabilities. The LNG-IUS can also provide endometrial protection in teens with chronic anovulation, and may be used to treat endometrial hyperplasia and cancer. This review examines the evidence supporting the use of the LNG-IUS in adolescents for these noncontraceptive benefits.

Effect of warfarin on menstruation and menstrual management of the adolescent on warfarin

AIM

The aim of this study was to review a consecutive cohort of adolescent females on warfarin to determine the effect of warfarin on menstruation, management options and their perceived efficacy.

METHODS

All female patients on warfarin, over the age of 10 years, as of 31 August 2006, were identified using the Department of Haematology (Royal Children's Hospital) warfarin database. The presence of menorrhagia was defined by clinical indicators.

RESULTS

Of 81 adolescent females on warfarin, 24 (30%) were referred to gynaecology due to a concern about heavy periods and one for anticipatory guidance, on the basis of impending menarche. In 18 cases (22% of the cohort), menorrhagia could be substantiated on the basis of clinical indicators. Nineteen patients required treatment for menorrhagia with the options for treatment being the combined oral contraceptive pill, subdermal hormone administrations, tranexamic acid and the progesterone-only contraceptive pill. Significant adolescent psychosocial stresses were identified in those adolescents taking warfarin.

CONCLUSIONS

Adolescent females on warfarin commonly suffer from menorrhagia. Adolescent review of all teenage girls receiving warfarin therapy is indicated.

Anovulatory bleeding in a 12-year-old as presenting sign for rare undifferentiated sarcoma

BACKGROUND

Abnormal uterine bleeding is a common phenomenon in perimenarchal females. Though most cases of abnormal bleeding are due to anovulatory bleeding or bleeding disorders, rare cases are attributable to underlying malignancy.

CASE

Here we report a 12-year-old female patient who presented with abnormal uterine bleeding three months after menarche. She was ultimately diagnosed with a pelvic sarcoma of unknown primary origin. She was subsequently treated with chemotherapy, whole pelvic radiation, and hysterectomy with bilateral salpingo-oophorectomy.

SUMMARY

Abnormal uterine bleeding unresponsive to conventional temporizing measures should be thoroughly evaluated. Management of pelvic malignancies in the pediatric population requires cooperation amongst specialists from an array of disciplines.

Overview of bleeding disorders in adolescent females with menorrhagia

Women bleed with menses, during childbirth, and after childbirth. Women are more likely to manifest a bleeding disorder as they have more opportunities to experience bleeding challenges in their lifetime. Bleeding disorders such as hemophilia and von Willebrand disease affect 2.5-3 million American women. The most common inherited bleeding disorder in the population is von Willebrand disease with an estimated prevalence of 1-2%. von Willebrand factor (vWF) is required to adhere platelets to exposed subendothelium and protects factor VIII from proteolysis in the circulation. The prevalence of vWF rises in studies involving women with menorrhagia, with estimates ranging as high as 10-20% in white women, and 1-2% among African American women. Other bleeding disorders seen in adolescents with menorrhagia are disorders of inherited platelet dysfunction, clotting factor deficiencies, thrombocytopenia, and disorders of the fibrinolytic pathway. Not only are women more likely to present early in their life with a bleeding disorder, they are also more likely to have other gynecologic manifestations as a result of these disorders. This article presents an overview of the problem and touches upon the different management strategies available.

Platelet disorders in adolescents

Acquired and inherited platelet disorders can present with bleeding symptoms during adolescence. Platelet disorders include disorders of platelet number and disorders of platelet function. In adolescent females with platelet disorders, menorrhagia is a common presenting bleeding symptom. Other associated bleeding symptoms are also primarily mucocutaneous, including epistaxis and bruising. Excessive bleeding may also occur after hemostatic challenges. Diagnosis of disorders of platelet function usually requires light transmission platelet aggregometry. Management of menorrhagia in the adolescent with platelet disorders requires both hematologic and gynecologic treatment.

Community Pharmacists' Therapeutic Recommendations for Heavy Flow, Androgen Excess, Fragility Fractures and Night Sweats in Menstruating Women

Background:

Physicians and menstruating women often ask pharmacists for recommendations about menstrual cycle–related problems. Progesterone and medroxyprogesterone may provide physiology-based treatment, but official indications in menstruating women in Canada are minimal.

Objectives:

To describe pharmacists' responses to vignette-based questions about the treatment of common clinical problems in menstruating women and review evidence-based therapies.

Methods:

A pharmacist interviewer administered an 11-item questionnaire to a random sample of community pharmacists. Questions were based on clinical vignettes in adolescent, pre- and perimenopausal women and related to heavy flow, polycystic ovary syndrome, premenopausal osteoporosis, perimenopausal night sweats and side effects/contraindications for estrogens and progesterone/progestins.

Results:

The participation rate was 58%, including equal numbers of male and female pharmacists. Seventy-two percent indicated that they would treat menorrhagia in an anemic 13-year-old with oral contraceptives — 21% would recommend ibuprofen and 86% iron. Half recommended that a 35-year-old smoker with heavy flow and acne stop oral contraceptives, but the other 50% recommended a switch to an oral contraceptive with cyproterone. For premenopausal osteoporosis, the majority recommended calcium and vitamin D, but 53% endorsed oral contraceptives — only 7% suggested cyclic medroxyprogesterone. For night sweats, the majority recommended progesterone/progestin in a regularly menstruating 42-year-old woman. Estrogens are contraindicated with past thrombosis and/or breast cancer family history, and they could cause nausea; 50% of pharmacists also attributed these adverse effects to progesterone/progestins.

Conclusions:

Community pharmacists vary widely in their treatment choices for common pre- and perimenopausal women's menstrual cycle–related problems. The evidence in support of most recommendations is minimal or lacking.