Dinkar BishtCourse-6th (2011-2012)

PUBERTY MENORRHAGIA

DEFINITION-Puberty menorrhagia is defined as excessive bleeding occurring between menarche and 19 years.

PATHPHYSIOLOGY

• During the prepubertal years, LH is secreted primarily at night in an episodic fashion. With the progression to puberty, LH peaks increase in a pattern similar to that seen at night. The timing of these LH pulses is crucial in establishing normal ovulatory cycles. Increases in basal LH as well as immature timing of pulses result in anovulatory cycles.

These cycles are characterized by levels of LH and FSH secretion that are sufficient to induce follicular development and oestrogen production but inadequate to induce follicular maturation and ovulation. Thus unopposed oestrogen stimulates endometrial growth. This ultimately outgrows its blood supply and architectural support, resulting in partial breakdown and shedding in an irregular manner.

• MAJOR• MAJOR

MINOR MINOR

Immature hypothalamo-pituitary axis• excess/unopposed estrogen • absent progesterone in anovulatory cycles

o coagulation disorderso blood dyscrasiasohypothyroidism

ETIOLOGY

Rare causes of pubertymenorrhagia.

-von Willebrand disease

It arises from a qualitative or quantitative deficiency of von Willebrand factor (vWF), a multimeric protein that is required for platelet adhesion. 

Schmidt's syndrome, also known as polyglandular deficiency syndrome, is the presence of Addison's disease and hypothyrodism in a single patient.

-Schmidt's syndrome

Aetiological factors

Anovulation

Hypothyroidism

Hematological cause

Pregnancy related complications

Fibroid uterus

Polycystic ovarian disease

Tuberculosis

Drugs (warfarin)

FACTORS DETERMINING THE CHOICE OF TREATMENT

◦Age

◦Parity

◦Histopathological changes in Endometrium

◦Need for contraception

◦Availability of treatment option

3

2

1Early control of excessive bleeding

Normalizing cyclical rhythms

Prevention of recurrence

TREATMENT

OBJECTIVES

Management

MILD PUBERTAL MENORRHAGIA

◦Reassurance

◦Maintenance of menstrual calendar, pictorial bleeding assessment chart & assessment of menstrual blood loss

◦Iron & Vitamin Supplementation

◦Periodic re-evaluation

MILD (..contd)• No Specific treatment required• Normal menstrual pattern occurs spontaneously

within 1 or 2 years

SEVERE PUBERTAL MENORRHAGIA

o ADMISSION OF THE PATIENTo Blood Transfusiono RULE OUT

Hypothyroidism-thyroid profile

Bleeding diathesis - FBC, platelet count, bleeding time, PTT,vwf antigen

drugsoTo Achieve Hemostasis

oHigh dose progestogeno Norethisterone acetate

o 1st 48hrs 5-10mg tdso Next 2 weeks 5-10mg bdo Next 1 week 5-10mg odo Then stop the drug

oTo Regularise Menstrual CyclesoCyclical progestogen for 6 months or longer

oRe-evaluation upto 12 months or longer if necessary

OCP-20-30 microgram tabs

mefenemic acid 500 mg tds for 6 days

OTHER DRUGS

tranexemic acid 500-1000 mg 8 hourly

GnRH-leuprolide -3.75 mg im monthly for 6 months

• DILATATION AND CURETTAGE (D&C)

– Last resort

– To rule out Tuberculous Endometritis (4% of cases)