DYSFUNCTIONAL UTERINE BLEEDING IN ADOLESCENTSMa. Stephanie Fay S.. Cagayan, MD, FPOGS, FPSSTD, FPSECPProfessorDept. Of Pharmacology and ToxicologyDept. Of Ostetrics and Gynecology!P College of MedicineObjectives1. Short review normal physiology of mestruation2. Define common termsAbnormal uterine bleeding, heavy menstrual bleeding and dysfunctional uterine bleeding. !dentify common causes of abnormal uterine bleeding per age group and focus on adolescents". Discuss management of D#$ in adolescents2Normal Menstrual Cycle!ntact, properly functioning %&Osystem'strogen(induced proliferative endometriumOvulation at midcycle with progesterone production fromthe corpus luteum&rogesterone(induced secretory endometrium!f pregnancy does not occur, hormones decline and withdrawal bleeding occursNormal Menstruation)actors that come into play for hemostasis*asoconstriction of spiral arteriesa higher thrombo+ane level ,&-)2. in relation to prostacyclin ,&-'2.fibrin platelet plug formationstabili/ation of the hemostatic platelet plug after activation of coagulation cascadeNormal Limits or Menstrual !arametersin t"e Mi#$Re%ro#ucti&e YearsClinical Dimensions Descriptive TermsNormal Limits(5th - 95% percentile))re0uency of menses,days.)re0uent 1 2"2ormal 2" ( 3!nfre0uent 4 35egularity of menses,cycle to cycle variationover 12 months6 in days.Absent*ariation of 2 to 27 days*ariation 4 27 days5egular!rregularDuration of flow ,days.&rolonged 4 3.72ormal ".8 ( 3.7Shortened 1 ".8*olume ,m9.%eavy 4 372ormal 8 ( 379ight 1 8Modified from the Consensus Meeting of Clinicians and Scientists (2007) Frasier IS et.al. Hum Reprod, !")Deinition o terms use# to #escri'e a'normalities o menstrual 'lee#in(A:#;'significantamountenoughtosignal cliniciantoinstituteprompt intervention to prevent further blood lossand may present in the conte+t of e+isting chronic A#$:%5O2!:abnormalinvolume,regularity, and8? of adolescents will have menses by 1".8 yo!rregular anovulatory mensesduring the first postmenarcheal yearsrange of 21("8 days2(@ days duration;hird gynecologic yearA7(37? of cycles 21(" days interval, similar to adultsSi+th gynecologic year2ormative cycle length established at a chronologic age 1>(2713Dysfunctional #terine $leedingDefined as abnormal vaginal bleeding without an identifiable pathologic condition. !n adolescents, D#$ is most often due to the anovulatory cycles that result from an immature hypothalamic(pituitary(ovarian a+is14Dysfunctional Uterine BleedingNo midcycle LH surge NO OVULATIONCystic follicular atresia producing only estrogens not progesterone Cystic follicular atresia producing only estrogens not progesterone Continos noppose! estra!iol pro!ctionContinos noppose! estra!iol pro!ctionEndometrial proliferation outgrows lood supplyEndometrial proliferation outgrows lood supplyNecrosis an! irre"lar #lee!in" Necrosis an! irre"lar #lee!in"Deligeoroglou E, et al. Abnormal uterine and bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecolgy. Gynecological Endocrinology, 20132!"1#$%&'%(Ovulatory D#$Defect in local endometrial hemostasisAlterations in prostaglandin production=ore &-'2 and &-!2 ,vasodilation and antiplatelet.9ess &-)2 ,vasoconstriction.!ncreased fibrinolytic activity heavy bleedingDeligeoroglou E, et al. Abnormal uterine and bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecolgy. Gynecological Endocrinology, 20132!"1#$%&'%('*A9#A;!O2 O) A2 ADO9'S:'2; B!;% A#$'valuation of Adolescent patient with D#$Detailed menstrual history and se+ual historyAge at menarche, 9ength of cycles Duration of menses, quantity, color, other associated symptomsOther medical conditions&sychosocial stressors, weight changes, eating and e+ercise habits, signs of hyperandrogenism)amily history of endocrinopathies or bleeding disorders'valuation of Adolescent patient with D#$&elvic e+amination!n non(se+ually active adolescents, speculum e+am is rarely necessary A one(finger digital e+am can assess for intravaginal foreign bodies and allow for palpation of the cervi+. !n se+ually active adolescents, a complete gynecologic e+am should be performed 'valuation of Adolescent patientwith D#$=inimum laboratory evaluation:$:&latelet count&rothrombin timeActivated partial thromboplastin time$leeding time DO 2O; )O5-'; &5'-2A2:C ;'S;T"era%eutic GoalsS%O5;(;'5=;o stop acute bleeding episode, hemodynamic stability , correct anemia 9O2-(;'5=;o prevent recurrence, return to normal cycles, prevent long term conse0uences of anovulationGeared towards etiologyTreatment o Acute Blee#in(=edicalmanagementofnon gestationalacuteabnormaluterine bleeding ,A#$. should be considered beforeanysurgicalprocedure, unlessbleedingissuspectedtobe duetointrauterinelesion,i.e. submucous myoma.=edical=anagement2O2(%O5=O2A9 ='D!:A;!O2SAntifibrinolyticsAntiprostaglandins%O5=O2A9 ='D!:A;!O2S'strogens and &rogestinsO:&s!#DDana/ol-n5% Analogues)ormonal *+erapyStabili/e endometrial proliferation and promote cyclic shedding=ore than >7 percent of adolescents with anovulatory uterine bleeding respond to hormonal therapy#nless there are contraindications, estrogen should be used in all patients who are actively bleeding because it promotes hemostasis=anagement of D#$Bith anemia and actively bleedingAggressive hormonal intervention :ombined O:&s 8 ug estrogen every A hours ," tabs