Acute management of severe anovulatory uterine bleeding in adolescents

This figure summarizes our suggested approach to acute management of severe anovulatory uterine bleeding, which we define as heavy menstrual flow with or without hemodynamic instability for a duration >7 days and/or hemoglobin <10 g/dL. Patients with severe anovulatory uterine bleeding that requires hospitalization should have a bleeding disorder evaluation (unless already performed). Ideally, the blood samples that are needed for the evaluation should be obtained before estrogen treatment is initiated or a transfusion is given. For additional details, including maintenance therapy regimens, long-term management of anovulatory uterine bleeding, and the evidence supporting the efficacy of these treatments, refer to related UpToDate content.

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

* Iron supplementation is started as soon as possible and is available as an intravenous infusion and oral tablets.

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

Δ 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.

◊ 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.

§ For sample taper regimens, refer to UpToDate content on anovulatory uterine bleeding.

¥ Promethazine 12.5 to 25 mg orally or per rectum or ondansetron 4 to 8 mg orally administered 30 to 60 minutes before each hormone dose.

‡ Once bleeding subsides, we begin a dose taper using a monophasic combined estrogen-progestin oral contraceptive pill.

† Options include tranexamic acid (preferred) and aminocaproic acid.

** We follow patients monthly until the hemoglobin is >10 g/dL and then every 3 to 6 months until the hemoglobin is >12 g/dL.

Graphic 148464 Version 1.0

UpToDate خرید پکیج

Acute management of severe anovulatory uterine bleeding in adolescents

خرید پکیج