Medical Care
Patients with abnormal (dysfunctional) uterine bleeding (AUB [DUB]) may present with chronic light flow in the form of irregular, prolonged, or intermenstrual bleeding. In most cases, this does not pose a significant health concern. Alternatively, patients with AUB can present with severe acute hemorrhage that warrants immediate medical attention. Patients require hospital admission for acute, poorly controlled bleeding that results in severe blood loss and, hence, symptomatic anemia; transfusion of packed red blood cells (PRBCs) should be considered for these patients.
Management must be tailored to the condition of each patient. For most patients, treatment consists of oral contraceptive pills (OCPs) and iron supplementation. Standard practice is that only patients with acute severe hemorrhage require more intensive treatment.
AUB has been classified into three categories of severity on the basis of the patient's hemoglobin (Hb) levels, as follows:
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Mild - Hb >11 g/dL
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Moderate - Hb 9-11 g/dL
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Severe - Hb < 9 g/dL
Medical therapy should be addressed accordingly. [29, 30, 31]
Light-flow (mild or moderate) abnormal uterine bleeding
After obtaining a complete history, performing a physical examination, and ordering appropriate laboratory studies, the clinician should reassure the patient and discuss the usual irregular nature of an adolescent's early menstrual cycles.
Menstrual regulation in the form of OCPs or cyclic progestins should be offered if the Hb level is below 11 mg/dL or, if the irregular bleeding has a significant impact on the patient's quality of life. [32]
Oral iron supplementation should be initiated if anemia is detected or if bleeding is persistent. Iron supplements can be prescribed to any patient after evaluation, according to the physician's judgment.
Further workup is indicated only when significant bleeding is occurring or when menstrual regulation does not correct the problem.
Acute (severe) abnormal uterine bleeding
Blood loss often is significant and may be life-threatening. Actively bleeding women who have unstable vital signs require emergency department (ED) management for fluid stabilization with intravenous (IV) crystalloid fluid replacement.
The underlying problem of an anovulatory cycle is bleeding from a hyperproliferative endometrium that has outgrown its estrogen supply; therefore, 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. Rarely, progestin medications alone (eg, medroxyprogesterone) are prescribed for those patients who cannot tolerate estrogen therapy.
Although infrequently required, blood product replacement should be considered if the patient has persistent heavy bleeding with a low hematocrit or if the patient continues to be symptomatic after bleeding has been controlled.
Once the patient has been stabilized and is able to tolerate oral therapy, iron supplementation should initiated as indicated by laboratory findings, and continuity should be established with follow-up care.
Surgical Care
Patients with AUB who do 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. In this situation, a gynecology healthcare team is required. The benefits and risks of surgical intervention and its long-term impact in relation to future childbearing must all be clearly addressed.
Complications
Complications are related to acute or chronic blood loss and the resulting anemia.
Patients who receive blood products should be onserved for transfusion-related complications, such as acute hemolytic reactions, bacterial sepsis, and viral infections.
Diet and Activity
Patients with anemia should be instructed about how to maintain a healthy diet rich in iron and folic acid.
Typically, limitation of activity is not indicated.
Prevention
Patients with a history of AUB who are sexually active and desire birth control should be placed on OCPs or cyclic progestins for menstrual cycle control. A backup birth control method (eg, condom use) is recommended.
Consultations
Consultation with a gynecologist (ideally one with expertise in adolescent medicine) is appropriate for any patient who has significant bleeding and anemia or in whom attempts at medical therapy do not resolve the problem. Abnormal laboratory findings should prompt referral to or consultation with an appropriate specialist.
Long-Term Monitoring
Long-term (≥6 months) suppression of the hypothalamic-pituitary-ovarian (HPO) axis should be considered for patients with bleeding that results in significant anemia. Mild anemia responds rapidly to once-daily oral iron supplementation. Iron supplements taken orally two or three times daily can cause gastointestinal complaints (eg, nausea and constipation) and subsequent noncompliance. The Office of Dietary Supplements (ODS) of the National Institutes of Health (NIH) is an excellent resource for iron dietary enhancement and iron supplement guidelines.
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Menstrual cycle.
