Patient Presentation
A 15-year-old female came to clinic with a 4 month history of a large amount of bleeding during her periods.
She had menarche at age 12, with periods lasting between 3-6 days and intervals from 4-6 weeks.
Her periods became regular around age 13 with duration of 5 days, intervals of 30 days and without excessive bleeding.
About 7 months ago she had significantly increased her running mileage for cross-country.
She lost about 5 pounds and during the sports season had menses that were more irregular with intervals of 20 – 35 days and duration of 3-5 days.
She described the menses flow also as “light to heavy.”After the season was over 3 months ago, she continued to be active with swimming and some running, but markedly cut down on her mileage.
Since that time her periods continued to be irregular and her last two periods lasted 7-9 days and she had heavier flow necessitating 10-12 pads or more tampons in a day for 4 days at least, and then several lighter flow days.
She also complained of passing clots during the first 3 days of her period.
She denied sexual activity currently or in the past. She denied any medications including aspirin or non-steroidal antiinflammatory drugs, complementary or alternative medicines or drugs of abuse.
The past medical history was negative including excessive bleeding or bruising.
The family history was negative for gynecological, obstetrical or hematological problems.
The review of systems was negative.
The pertinent physical exam showed a thin female with weight of 114 pounds (10-25%) and a height of 68 inches (90%). She had no tachycardia and no orthostasis.
Skin showed a small bruise on her upper thigh and no hirsutism. She had some closed comedones along her nasal folds and forehead. She had no thyromegaly.
Genitourinary examination showed a virginal female, Tanner stage V, with normal external genitalia. Pelvic examination performed through the rectum was normal.
The laboratory evaluation showed a complete blood count with hemoglobin of 11.2 g/dl and hematocrit of 35%, and platelets of 17.5 x 1000/mm2.
Pregnancy and sexually transmitted infections urine testing were negative.
Prothrombin time, partial thromboplastin time and thyroid stimulating hormone were normal.
The diagnosis of dysfunctional uterine bleeding was made. The bleeding was most like due to anovulation secondary to immature hormonal regulation and increased stress and weight loss from her sports activity.
She had a mild anemia and because she was going to be increasing her sports activities again with track season, it was decided to use oral contraceptive pills to try to regulate her menstrual cycles.
She was given iron supplementation and was to return to clinic in two months for follow-up and call in the interval if problems became worse.
Discussion
Dysfunctional uterine bleeding is prolonged, excessive or frequent, unpatterned uterine bleeding that is not related to an anatomical uterine abnormality or systemic cause.
It is very common in adolescents and is a clinical diagnosis. The main complication is anemia.
Menarche occurs from 9-16 years with an average of 12.4 years in the United States. Normal ovulatory cycles can take up to 5 years after menarche to occur.
Normal menses last 2-7 days, with an interval of 21-35 days and have an upper limit of normal menstrual flow of 60-80 ml.
Menstruation occurs through the regulation of numerous hormones, primarily estrogen and progesterone, but also luteinizing hormone, follicle stimulating hormone and others.
Estrogen reaches adult levels fairly early after menarche, usually in the second year.
Progesterone though may not reach adult levels until 5 years.
During normal menstruation the follicular phase lasts from the first day of menstrual flow until ovulation or about 14 days. Its primary hormone is estrogen made by ovarian follicles.
The luteal phase begins with ovulation and ends with menstruation or conception. Its primary hormone is progesterone made by the corpus luteum.
Because full adult hormonal levels and appropriate regulation may not occur for 5 years, anovulatory cycles (i.e., cycles where the ovarian follicles release an egg and make then make a corpus luteum) occur frequently.
Therefore, there is estrogen available to grow the uterine endometrial lining, but little or no progesterone to oppose it.
Unopposed estrogen causes the endometrial lining to outgrow its blood supply causing breakdown and shedding; estrogen also causes decreased vasoconstriction through several mechanisms leading to continued bleeding.
The result is dysfunctional uterine bleeding.
Initial laboratory evaluation usually includes a complete blood count, prothrombin time, partial thromboplastin time, pregnancy test and sexually transmitted infection screening.
If treatment does not alleviate the problem along with careful monitoring then further testing for thyroid stimulating hormone, glucose, prolactin, dehydroepiandrosterone sulfate testosterone, ristocetin factor
and imaging usually by ultrasound are undertaken.
Learning Point
Patients with significant bleeding, acute abdominal pain and associated problems need a comprehensive evaluation possibly including gynecology, surgery and radiology consultations.
For patients with dysfunctional uterine bleeding that is due to anovulation, treatment varies depending on severity.
- If the patient has no anemia and is minimally worried, then she can usually be reassured and monitored. A menstrual calendar is useful to record the pattern and symptoms.
- If the patient has mild anemia (i.e. hemoglobin > 11 g/dl or hematocrit > 33%), then iron supplementation can be used and the patient again monitored while waiting for menstrual normalization.
If the patient is sexually active or the bleeding is impacting the patient’s quality of life, oral contraception can be used for simultaneous contraception and menstrual normalization. - If the patient has moderate anemia (i.e. hemogblobin 9-11 g/dl or hematocrit 27-33%), then low-dose estrogen-progesterone oral contraceptive tablets can be used by taking 2-4 pills every 4-8 hours until the bleeding stops.
Then the dosage is gradually decreased until 1 tablet/day for 2-3 weeks.
At that time the tablets are stopped and withdrawal bleeding should occur.
A cyclic low-dose estrogen-progesterone oral contraception regimen is then begun for an additional 2-3 cycles.
Iron supplementation should also be used. - If the patient has severe anemia (i.e. hemoglobin < 9 g/dl, hematocrit < 27% or dropping parameters), patients need to monitored closely and hemodynamically stabilized as necessary. Oral contraceptives are initiated immediately also. One option is to use 1-2 pills 4 times/day for 4 days, 3 times/day for 4 days, 2 times/day for 2-3 weeks and then allow withdrawal bleeding for 7 days.
A cyclic low-dose estrogen-progesterone oral contraception regimen is then begun for an additional 3-6 cycles. Iron supplementation should also be used.
Intravenous estrogen is not usually utilized but may be necessary if there is brisk bleeding.
Antiemetics may be needed while giving estrogen treatment because estrogen may cause nausea and vomiting.
Counseling for sexually transmitted infection prevention should also be given to all adolescents as part of health supervision.
Questions for Further Discussion
1. What is the differential diagnosis of vaginal bleeding?
2. When should gynecology be consulted for abnormal uterine bleeding?
Related Cases
- Disease
- Dysfunctional Uterine Bleeding
Uterine Diseases
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Uterine Diseases
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:252-254.
Aeby AC, Frattarelli LC. Dysfunctional Uterine Bleeding. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/TOPIC628.HTM (rev. 5/22/06, cited 12/3/07).
Matytsina LA, Zoloto EV, Sinenko LV, Greydanus DE. Dysfunctional Uterine Bleeding in Adolescents: Concepts of Pathophysiology and Management. Prim Care. 2006 Jun;33(2):503-15.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
January 14, 2008
Pediatric Education 