Dysfunctional Uterine Bleeding in Pediatrics Treatment & Management
- Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Andrea L Zuckerman, MD more...
Patients with dysfunctional uterine bleeding (DUB) may present with 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 severe acute hemorrhage that warrants 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.
DUB has been classified into categories of severity on the basis of hemoglobin (Hb) levels, as follows:
Mild - Hb >11 g/dL
Moderate - Hb 9-11 g/dL
Severe - Hb < 9 g/dL
Therapy should be addressed accordingly.[22, 23, 24]
Light-flow (mild or moderate) dysfunctional uterine bleeding
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 the Hb level is less than 11 mg/dL or if the irregular bleeding has a significant impact on the patient's quality of life.
Initiate oral iron supplementation if anemia is detected or if bleeding is persistent. Iron can be offered to any patient after evaluation, according to physician judgment.
Further workup is indicated only in the case of significant bleeding or when menstrual regulation does not correct the problem.
Acute (severe) dysfunctional uterine bleeding
Blood loss often is significant, and may be life threatening. Actively bleeding women who have unstable vital signs need intravenous 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 physiologic 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, though infrequently required, is indicated when the patient has persistent heavy bleeding with a low hematocrit or when the patient has symptomatic anemia after bleeding has been controlled.
Once the patient has been stabilized and able to tolerate oral therapy, initiate iron supplementation as indicated by laboratory findings and establish continuity with follow-up care.
The rare patient with DUB who does not respond to medical therapy may require endometrial curettage, hysteroscopic evaluation, or both. In life-threatening circumstances where medical therapy is ineffective or contraindicated, endometrial ablation or hysterectomy may be the only reasonable alternative. Given this situation, the medical provider should address the risks and benefits of surgical intervention and the implications for future childbearing, as well as other options for child rearing.
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.
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