AUB in an adolescent patient

Question 1

A 12-year-old girl is referred to your office by her pediatrician. She arrives with her mother. She experienced her first menstrual cycle 14 months ago and has had irregular, heavy menstrual periods since that time. She had no abnormal bleeding at the time of a tonsillectomy. She has no family history suggestive of blood disorders. Her vital signs are within normal limits: quantitative human chorionic gonadotropin level, less than 5 mIU/mL; hemoglobin level, 11.1 g/dL; hematocrit, 33.2%; mean corpuscular volume, 75 cubic micrometers; platelet count, 342 × 103 per microliter; prothrombin time, 12.2 seconds; partial thromboplastin time, 27.4 seconds; and thyroid-stimulating hormone level, 3.4 mIU/L. The best next step in management is:

(A) iron supplementation
(B) office pelvic examination
(C) additional coagulation studies 
(D) pelvic ultrasonography
(E) oral contraceptives

Answer 1

(A) iron supplementation

Question 2

When should an adolescent see a gynecologist for the first time?

Answer 2

Around 13-15 y/o - talk about preventative care and safe sexual practice if applicable; pelvic exam not vital

Question 3

What is the most common cause of abnormal bleeding in adolescents?

Answer 3

Anovulatory bleeding: 55-82% of girls in the first 24 months after menarche - likely d/t relative immaturity of the HPO axis

Question 4

How should anemia caused by abnormal uterine bleeding be managed in an adolescent patient?

Answer 4

Mild anemia (Hct >33% or Hb >11g/dl): iron supplementation; contraception as needed

Moderate anemia (Hct 27-33% or Hb 9-11 g/dl): oral contraceptives to help with AUB + iron supplementation

Severe anemia (Hct <27% or Hb <9 g/dl): start with OCPs (1 pill q6h until bleeding decreases, then tapered dose to complete 21d pill pack) and antiemetic for this dose of estrogen –> for the next 3 months need OCPs in normal doses for contraception + iron for anemia –> then reevaluate to see if OCPs are still necessary