Case Files Pediatrics, (LANGE Case Files) 4th Ed.

CASE 40

A 16-year-old adolescent female presents to your clinic complaining of very heavy menstrual bleeding for the last 6 months. She notes that her cycles are regular, occurring every 29 days, but they last for 10 days and she goes through 10 to 12 pads per day. Her last period ended a week ago, and she now complains of dizziness when she stands up. She denies concurrent vaginal discharge or abdominal pain. Her past medical and family histories are negative for bleeding problems. Her menarche was at 12 years of age, and she started having regular menstrual cycles at 14 years of age. She denies all forms of sexual activity. Her examination is significant for mild resting tachycardia and orthostatic hypotension. Her nail beds and conjunctiva are pale. A urine pregnancy test is negative, and her hemoglobin is 10 g/dL.

Image What is the most likely diagnosis?

Image How would you manage this patient?

ANSWERS TO CASE 40: Dysfunctional Uterine Bleeding

Summary: An adolescent female complains of heavy but regular menstrual bleeding that has resulted in anemia and orthostatic hypotension.

• Most likely diagnosis: Dysfunctional uterine bleeding (DUB).

• Management: Iron supplement and monophasic low-dose oral contraceptive pills (OCPs) for 3 to 6 months with a follow-up hemoglobin in 6 weeks.

ANALYSIS

Objectives

1. List the diagnostic possibilities for abnormal uterine bleeding.

2. Describe the appropriate evaluation of abnormal uterine bleeding.

3. Differentiate between the different managements of DUB based on symptoms and type of bleeding.

Considerations

Menstrual bleeding that leads to anemia and orthostatic hypotension is not typical, and requires further investigation. Excessive bleeding may be caused by pregnancy; although she denies sexual activity, a urine pregnancy test should be part of the evaluation. Sexually transmitted diseases, malignancy, and trauma should also be considered.

APPROACH TO:

Dysfunctional Uterine Bleeding

DEFINITIONS

MENORRHAGIA: Excessive and/or prolonged uterine bleeding with a regular menstrual cycle.

METRORRHAGIA: Irregular uterine bleeding between menstrual cycles.

MENOMETRORRHAGIA: Irregular uterine bleeding with excessive and/or prolonged flow.

CLINICAL APPROACH

Dysfunctional uterine bleeding is abnormal flow that occurs either excessively in a regular cycle (menorrhagia) or irregularly and not related to the normal menstrual flow (metrorrhagia). Dysfunctional uterine bleeding is a diagnosis of exclusion; other diagnoses must be considered first. Of young women presenting with abnormal vaginal bleeding, about 9% will have an organic cause such as ectopic pregnancy or threatened abortion; other potential causes include infections (cervicitis, human papillomavirus [HPV], trichomonas), trauma, hormonal contraceptives and other medications, hypothyroidism, foreign body, or malignancy. The remainder of women will have no demonstrable cause for their bleeding and are diagnosed with dysfunctional, or abnormal, uterine bleeding.

The typical presentation is that of a teen with regular menstrual cycles who then develops prolonged or heavy menstrual bleeding, or irregular bleeding. The bleeding is usually painless. Important aspects of the history include prior episodes of bleeding, the length of the woman’s cycle, the number of days of bleeding, and the severity of the bleeding (can be established by asking about the number of pads or tampons used per day). Family history should include others with bleeding problems such as excessive hemorrhage after surgery and women requiring hysterectomy after childbirth.

After verifying the patient is not pregnant, the next most important laboratory evaluation is the hemoglobin. The degree of anemia helps categorize the severity of bleeding and helps guide management (Figure 40-1). Women with a hemoglobin more than 12 g/dL are considered to have mild bleeding, and may be managed with iron supplements alone and with careful follow-up. A hemoglobin of 9 to 12 g/dL is considered a result of moderately severe bleeding; treatment includes iron and monophasic OCP. Women with a hemoglobin less than 9 g/dL are considered to have severe bleeding, and may need hospitalization and transfusion. Intravenous estrogen (Premarin) and high-dose oral contraceptives are used until the bleeding stops; further bleeding despite these measures may require dilatation and curettage. Although these high doses of estrogen raise theoretical concerns about thrombotic events, none have been reported with the short-term use required in this condition.

Image

Figure 40-1. Evaluation of dysfunctional uterine bleeding. CBC, complete blood count; Hgb, hemoglobin; OCP, oral contraceptive pills. (Reproduced, with permission, from Kaplan DW, Love-Osborne L. Adolescence. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR, eds. Current Diagnosis and Treatment in Pediatrics. 19th ed. New York, NY: McGraw-Hill; 2009:128.)

Patients with dysfunctional uterine bleeding continue oral contraceptives for 3 to 6 months. After the menstrual cycle is regular and irregular bleeding has ceased, careful withdrawal of the OCP may be attempted if desired with close follow-up. Iron supplementation should be continued for 2 months after the anemia is resolved.

COMPREHENSION QUESTIONS

40.1 A 15-year-old adolescent female presents to the local hospital emergency center complaining of several days of left-sided abdominal pain, mild vaginal bleeding, and dizziness. Upon further questioning you learn that she has had near-syncopal episodes the last few times she has tried to stand up. She denies fever, sexual activity, previous episodes of mid-cycle vaginal bleeding, and abdominal or genitourinary trauma. On examination, she is pale and tachycardic. She has abdominal pain with rebound and guarding in the upper and lower left quadrants that radiates to the back. Her hemoglobin is 5 g/dL, her white count is 12,000/mm3, and her platelet count is 210,000/mm3. Her serum B-HCG is 1800 mIU/mL. Which of the following is the most likely diagnosis?

A. Metrorrhagia with subsequent anemia

B. Pelvic inflammatory disease

C. Salicylate overdose

D. Ruptured ectopic pregnancy

E. Uterine malignancy

40.2 A 13-year-old adolescent female comes to the office for a preparticipation sports physical before the start of the basketball season. She has no complaints, but wants to discuss the human papillomavirus (HPV) vaccine some of her friends have received. Which of the following is an accurate statement about human papillomavirus and the vaccine?

A. The HPV vaccine is indicated only once a woman becomes sexually active.

B. HPV types 6 and 11 are high cancer risk serotypes and are included in the vaccine.

C. HPV vaccine helps prevent cervical cancer but not genital warts.

D. HPV types 16 and 18 are associated with the majority of cervical cancers.

E. Syncope after injection has been reported and is a unique adverse reaction to HPV vaccine.

40.3 A 16-year-old presents to your clinic with a complaint of persistent vaginal bleeding. She had been seen 3 months ago when you noted a mild anemia of 13 g/dL, diagnosed her with dysfunctional uterine bleeding, and started her on iron supplements. Today she is listless and pale. Her hemoglobin in your clinic is 6 g/dL, her platelet count is normal, and her urine pregnancy test remains negative. You admit her to your local hospital and order a transfusion of packed red blood cells. In addition to stabilizing her circulatory system, which of the following is the most appropriate next step in the acute management of her condition?

A. Monophasic low-dose oral contraceptive (OCP)

B. Intravenous conjugated estrogens (Premarin) and high-dose combination OCP

C. Hysterectomy

D. Discharge after transfusion with iron supplementation

E. Triphasic low-dose OCP

40.4 A 19-year-old adolescent female presents with a temperature of 101.2°F (38.4°C), lower abdominal pain, bloody vaginal discharge, and dyspareunia. She has no nausea or vomiting, and is tolerating fluids well. She has cervical motion tenderness on examination. Her urine pregnancy test is negative, and an ultrasound of her right lower quadrant is negative for appendicitis. Which of the following is the appropriate outpatient management for her likely condition?

A. Levofloxacin, 500 mg orally once a day for 14 days as monotherapy

B. Ofloxacin, 400 mg orally twice a day for 14 days as monotherapy

C. Ceftriaxone, 250 mg IM in a single dose as monotherapy

D. Levofloxacin, 500 mg orally once a day, and doxycycline, 100 mg orally twice a day, both for 14 days

E. Ceftriaxone, 250 mg IM as a single dose and doxycycline, 100 mg orally twice a day for 14 days

ANSWERS

40.1 D. The classic triad of abdominal pain, vaginal bleeding, and amenorrhea only occurs in about 50% of cases of ectopic pregnancy. As ectopic pregnancy is the leading cause of pregnancy-related death in the first trimester; a physician must consider the diagnosis for any woman of childbearing age with abdominal pain. Risk factors for an ectopic pregnancy include pelvic inflammatory disease (PID), intrauterine device (IUD), previous ectopic pregnancy, previous tubal surgery, increasing age, use of fertility drugs, and smoking. Since this patient is hemodynamically unstable, admission and surgery are indicated; however, hemodynamically stable patients with an unruptured ectopic pregnancy and good follow-up may be managed expectantly or treated with methotrexate.

40.2 D. Quadrivalent human papillomavirus vaccine (Gardasil) was licensed in 2006, and is indicated for the prevention of HPV types 6, 11, 16, and 18. Types 6 and 11 cause about 90% of all genital warts, but carry a low risk of malignancy. Types 16 and 18 cause about two-thirds of all cervical cancer cases. Immunization before sexual debut is ideal, but even women who are sexually active may benefit from the vaccine; as there is no commercially available screening test to determine the serotypes to which a woman has been exposed, the vaccine may still provide some protection. Boys, too, receive this vaccination beginning at the age of 11 years in the effort to prevent warts and spread of the virus. The vaccine is a three-dose series. Common side effects include headache and pain at the injection site. Anaphylaxis to yeast is a contraindication. Syncope has been reported in the adolescent population with all vaccines; current recommendations suggest observing adolescents for 15 minutes after immunization.

40.3 B. Based on her anemia, this adolescent’s dysfunctional uterine bleeding is classified as severe, and warrants hospitalization. Stabilization of her circulatory system is the first priority, and then steps must be taken to stop the bleeding. Intravenous conjugated estrogens (Premarin) in conjunction with a high-dose OCP is the next step. If this treatment is successful in decreasing the bleeding, she can be continued on high-dose OCP for a month and then moved to a low-dose OCP. If she continued to have bleeding after IV Premarin and a high-dose OCP, dilatation and curettage may be necessary.

40.4 E. More than one million women develop pelvic inflammatory disease (PID) in the United States each year, and more than a quarter of these require hospitalization. PID is most common in the teen population, with decreasing incidence with increasing age. As presenting signs and symptoms are variable, diagnosis can be difficult. The Centers for Disease Control and Prevention (CDC) recommends that empiric treatment should be started if a young woman at risk for PID presents with lower abdominal or pelvic pain, no other cause for the pain can be identified, and the woman has: (1) cervical motion tenderness, (2) uterine tenderness, or (3) adnexal tenderness. Treatment is aimed at both gonorrhea and chlamydia. Recent surveillance by the CDC has shown fluoroquinolone-resistant gonorrhea is widespread in the United States, so fluoroquinolones are no longer recommended in the treatment of PID.


CLINICAL PEARLS

Image Pregnancy and STDs must be considered in any adolescent with abnormal vaginal bleeding.

Image Dysfunctional uterine bleeding can be excessive flow with normal intervals (menorrhagia), or flow with irregular intervals (metrorrhagia).

Image Cessation of bleeding can usually be achieved through the use of oral contraceptives; occasionally, intravenous estrogen is required.


REFERENCES

Buzzini SR, Gold MA. Menstrual disorders. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:561-566.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010; 59(No. RR-12):63-67.

Cromer B. Abnormal uterine bleeding. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics, 19th ed. Philadelphia, PA: Elsevier; 2011:688-690.

Cunningham FG, Leveno KJ, Bloom SL, et al., Ectopic pregnancy. Cunningham FG, Leveno KJ, Bloom SL, et al: Williams Obstetrics, 23e. Available at: http://www.accessmedicine.com/content.aspx?aID=6020319. Accessed April 24, 2012.

Daley M F, O’Leary ST, Simoes E A, Nyquist A-C. Immunization. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR, eds. Current Diagnosis & Treatment Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:267-268.

Edman JC, Shafer M. Dysfunctional uterine bleeding. In: Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA, eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:298-299.

Sass AE, Kaplan DW. Dysfunctional uterine bleeding. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR, eds. Current Diagnosis & Treatment Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011: 132, 134-135.



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