Dysfunctional Uterine Bleeding in Teens: Think Anovulation.
In adolescents who bleed irregularly, 74% have anovulation with no other pathology present. Menses don't become regular until 2-21/4 years after menarche, Dr. Linda Grant reminded physicians at a meeting on clinical pediatrics sponsored by Boston University.
The most common question she hears from patients with menometrorrhagia is "How do I make it stop?"
First, she makes sure the bleeding is abnormal by eliciting the patient's history.
Asking how many menstruation pads the teenager uses in a day can be misleading because "some people change their pads at a drop of blood; others wait until it soaks through," observed Dr. Grant, medical director of Boston public schools.
She's careful to ask how many pads a day the patient completely soaks through. Normal bleeding usually means 2 or 3, and it's rare to hear 9 or 10.
Once the differential diagnoses of pregnancy and STDs have been ruled out, Dr. Grant prescribes a regimen of oral contraceptives to rein in the anovulation.
Patients take an oral contraceptive four times a day for 2 days, followed by one pill three times a day for 3 days, one pill twice a day for the next 14-16 days, and then 7 days of withdrawal and bleeding.
After one cycle, the maintenance dosage is one pill once a day for 3 months.
At the higher dosages, antiemetics are needed, she noted.
The type of oral contraceptive doesn't matter as long as it's monophasic. Triphasics attempt to mimic the natural menstrual cycle but may exacerbate an anovulating teenager's hormonal irregularity.
Dr. Grant makes a point of removing the placebo pills in the contraceptive pack before giving the medication to teenagers, to prevent them from inadvertently taking the placebo pills when they should be taking active ones.
In anovulation, patients experience constant bleeding with no rhythmicity because progesterone is not present to stabilize estrogen levels in the endometrium. "What you have is a constant, bubbling cauldron in the lining of the uterus," she said.