Acute management of mild to moderate anovulatory uterine bleeding in adolescents

BP: blood pressure; CT: Chlamydia trachomatis; GC: gonococcal; IUD: intrauterine device; LNG: levonorgestrel; NAAT: nucleic acid amplification test; SLE: systemic lupus erythematosus.

* A urine pregnancy test should be performed to confirm the absence of pregnancy before initiating treatment for anovulatory bleeding.

¶ Send urine for GC and CT NAATs concurrently with initiating treatment for anovulatory bleeding to confirm the absence of chlamydia and gonorrhea, which can cause bleeding related to endometritis.

Δ The contraceptive patch or vaginal ring are alternatives for patients who prefer a contraceptive option that does not require daily use.

◊ Contraindications to estrogen that adolescents are more likely to have include migraine with aura, current or previous venous thromboembolism, elevated BP (systolic BP ≥140 or >90th percentile for age, diastolic BP ≥90 or >90th percentile for age), known thrombogenic mutations, SLE with positive or unknown antiphospholipid antibodies, <21 days postpartum. Certain medications (eg, some anticonvulsants and rifampin) decrease the effectiveness of estrogen-containing contraceptives; for specific interactions, refer to the drug interactions program included within UpToDate. The risk for thromboembolism is increased with estradiol daily doses >35 micrograms.

§ An LNG IUD or depot medroxyprogesterone are alternative options for patients with estrogen contraindications who do not want to take a daily pill.

¥ For sample hormone tapers, refer to UpToDate uterine bleeding management topics.

‡ Promethazine 12.5 to 25 mg orally or per rectum or ondansetron 4 to 8 mg orally administered 1 hour before each hormone dose.