Some OB/GYNs might be concerned when the office schedule lists an initial teen visit with the chief complaint of abnormal uterine bleeding (AUB), but others will look forward to the chance to get to know a new adolescent patient. Teenagers never fail to surprise and delight doctors with their unfiltered questions and vacillating embarrassment mixed with curiosity about their developing bodies.
AUB is defined as uterine bleeding of an unexpected amount, duration or regularity. The most common cause in early adolescence is simply immaturity of the hypothalamic-pituitary-ovarian axis, with anovulatory bleeding resulting in skipped periods, unpredictable, prolonged and sometimes heavy bleeding. However, it may also be the first indication of a more serious underlying disorder.
Assessing AUB in Adolescents
Work with the patient to map out a careful history on a menstruation calendar or app, with special attention to the amount and duration of the bleeding. How many soaked pads/tampons were there? Did the patient wear thin liners, thick pads, a menstrual cup, etc.? Did they experience accidents requiring clothing changes or cancelled school and social activities? This information will help paint a picture of the young patient's predicament and the impact it has on their quality of life. Occasionally, reassurance and a discussion of what is normal is all a young person needs.
Other times, treating AUB requires a deeper dive. Look for possible endocrine or anatomic causes, and screen for relevant genetic disorders. Do not forget to screen for sexually transmitted infections and pregnancy as well, especially if the bleeding is acute and heavy. Encourage teen patients to be transparent about their sexual activity, as it impacts their health. Work to deliver trauma-informed care and screen for trauma such as sexual assault or abuse for patients of all ages.
In rare cases, when there is life-threatening bleeding, hospitalization, intravenous estrogen therapy or surgery might be necessary.
When to Look for Underlying Clotting Issues
The physical exam should include documentation of skin pallor, any petechiae, bruising and vital signs. If there are no worrisome findings, the initial lab work could be a simple finger-stick hemoglobin test. However, approximately one-third of adolescents with AUB may have underlying coagulopathy, according to research published in the Journal of Clinical Research in Pediatric Endocrinology (JCRPE).
If findings warrant, the JCRPE research recommends clinicians assess:
- A complete blood count
- Prothrombin time
- Partial thromboplastin time
- Activated partial thromboplastin time
- Fibrinogen level
Preliminary screening for Von Willebrand's disease, platelet dysfunction, thrombocytopenia and clotting disorders may also be necessary.
Investigate Further With Ultrasound
Fortunately, most teens respond to medical therapy for mild to moderate abnormal bleeding. Those who do not respond to medical therapy may benefit from a transabdominal ultrasound to look for underlying gynecological problems.
Structural abnormalities of the uterus or adnexa are rare in this age group, but ultrasound images will reassure the patient and their family that their reproductive organs are normal in appearance. The PALM-COEIN classification system for AUB, originally published in Gynecology and Obstetrics, notes that besides coagulopathies, ovulatory dysfunction and adenomyosis, endocrine disorders and iatrogenic causes can contribute to AUB.
A classic sign of adenomyosis easily identified on ultrasound is the fan shaped shadowing seen in this image. Ultrasound imaging provides a clearer picture of changes to the junctional zone, such as thickening or irregularity, and can provide an accurate means for diagnosis. A 3D ultrasound sweep in particular offers a clear view of the coronal plane, not seen in 2D.
3D Adenomyosis using Voluson™ HDlive™ imaging tool.
Those underlying endocrine disorders, other than hormonal immaturity, include polycystic ovarian syndrome, thyroid disorders and pituitary prolactinomas. Iatrogenic causes may be due to the use of hormonal therapy, an antidepressant, blood thinners or an IUD that has shifted. Treatment could be as simple as watchful waiting, high dose NSAIDs, oral contraceptives or a levonorgestrel-releasing intrauterine device.
3D Polycystic Ovary shown using a Voluson™ E10.
OB/GYNs Can Help Boost a Teen's Quality of Life
Most teenagers are busy worrying about fitting in and juggling their school and extracurricular responsibilities. They are experiencing a great deal for the first time and learning to manage the many challenges of daily life. They should not need to manage abnormal uterine bleeding while exploring on a field trip with their class, playing in a championship soccer game or dancing at their annual recital.
Helping teens navigate gynecological problems in adolescence, while establishing a healthy relationship with a trusted clinician, is one of healthcare's sweetest rewards.
