Dysfunctional Uterine Bleeding in Pediatrics Treatment & Management

Patients with dysfunctional uterine bleeding (DUB) may present with a chronic light flow in the form of irregular, prolonged, or intermenstrual bleeding that is a nuisance but not a significant health threat. Alternatively, patients with DUB can present with acute torrential hemorrhage requiring immediate medical attention. Tailor management to the condition of the individual patient. For most patients, treatment consists of oral contraceptive pills and iron supplementation. Only patients with acute severe hemorrhage require more intensive therapy. Some authors classify DUB as mild, moderate, or severe based on hemoglobin (Hgb) levels and tailor therapy accordingly.^{[11, 12, 13]}

Management of light-flow DUB (mild is Hgb >11 g/dL, moderate is Hgb 9-11 g/dL)

After obtaining a complete history, performing a physical examination, and obtaining the appropriate laboratory studies, reassure the patient and discuss the usual irregular nature of an adolescent's early menstrual cycles.

Offer menstrual regulation in the form of oral contraceptive pills or cyclic progestins if Hgb level is less than 11 mg/dL or if the irregular bleeding has a significant impact on the patient's quality of life.

Further workup is indicated only in the case of significant bleeding or when menstrual regulation does not correct the problem.

Institute iron therapy if an anemia is detected or if bleeding is persistent. Iron can be offered to any patient after evaluation, according to physician judgment.

Management of acute DUB (severe is Hgb < 9 g/dL)

Blood loss often is significant, and may be life threatening. Actively bleeding women who have unstable vital signs need IV access and rapid crystalloid fluid replacement.

Because the underlying problem is bleeding from a hyperproliferative endometrium that has outgrown its estrogen supply, the primary therapeutic goal is reestablishment of estrogen supply in the form of high-dose oral or parenteral estrogen. Secondary treatment is aimed at stabilizing the endometrium with exogenous progestin therapy. The physiological response to estrogen is similar, regardless of the route of administration. Therefore, parenteral therapy is reserved for unstable patients or for patients who are unable to tolerate oral medications. Reserve progestin medications alone (such as medroxyprogesterone) for the rare patient with a contraindication to estrogen therapy.

Blood product replacement, while infrequently required, is indicated when the patient has persistent heavy bleeding with a low hematocrit or in women with a symptomatic anemia after bleeding has been controlled.

The rare patient with DUB who does not respond to medical therapy may require endometrial curettage and/or hysteroscopic evaluation. In life-threatening circumstances in which medical therapy is ineffective or contraindicated and future childbearing is not recommended, endometrial ablation or hysterectomy may be the only reasonable alternative.

Consultation with a gynecologist (ideally one with expertise in adolescent medicine) is appropriate for any patient with significant bleeding and anemia or when attempts at medical therapy do not resolve the problem. Abnormal laboratory findings should prompt referral to or consultation with an appropriate specialist.

Teach patients with significant anemia about a diet that is rich in iron and folic acid.

Limitation of activity is not necessary.