Unpredictable, heavy, and prolonged menses may impair school attendance and social functioning; iron deficiency anemia is associated with lower academic scores. Treatment is indicated for heavy menses. Chronic and acute bleeding can be managed with CHCs; multiple daily doses may be required until blood loss is controlled. Occasionally uncontrollable bleeding requires hospitalization for intravenous fluids and high-dose estrogen. Uterine curettage is rarely indicated in adolescents. Iron therapy is also important. Use of CHCs to regulate menstruation and allow the hypothalamic-pituitary-gonadal axis to mature is appropriate; only 6 to 12 months of therapy may be required. CHCs are paramount in the management of heavy menstrual bleeding in individuals with bleeding disorders (von Willebrand disease), although adjuvant therapy with tranexamic acid may be needed for management of any scheduled withdrawal bleeds. Parents are often concerned that CHC use will cause their daughter to become sexually active, but literature and experience do not support this.
Pregnancy, including ectopic pregnancy Infection—usually sexually transmitted Endocrine disorder—thyroid disorder, PCOS, pituitary disorder Blood dyscrasia Systemic disease Trauma Medications Contraception Vaginal, cervical, or uterine disorders Ovarian tumor/cyst Foreign body
PCOS, Polycystic ovary syndrome.
*When all excluded, the diagnosis of dysfunctional uterine bleeding can be made.
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The most common gynecologic complaint of young women is painful menstruation, or dysmenorrhea, during the first 1 to 3 days of bleeding. Primary dysmenorrhea is defined as pelvic pain during menstruation in the absence of pelvic pathology and is a feature of ovulation, typically developing 1 to 3 years after menarche, with an increasing incidence to the age of 24, as ovulatory cycles are established. The release of prostaglandins and leukotrienes from the degenerating endometrium after progesterone levels decline causes increased uterine tone and increased frequency and dysrhythmia of uterine contractions. This creates excessive uterine pressures and ischemia that heightens the sensitivity of pain fibers to bradykinin and other physical stimuli.
Secondary dysmenorrhea is menstrual pain associated with pelvic pathology and is caused most frequently by endometriosis or pelvic inflammatory disease. Adolescents with endometriosis usually have mild to moderate disease, but girls with obstructed outflow tracts tend to have severe endometriosis soon after menarche. The types of dysmenorrhea usually can be distinguished by history and physical examination. Ultrasound is preferred as the initial screen for obstructing genital tract lesions. Magnetic resonance imaging may be useful in complex reproductive tract anomalies. Laparoscopy is required to diagnose endometriosis and pelvic inflammatory disease with certainty, although it usually is reserved for patients who fail medical therapy.
Treatment of primary dysmenorrhea should be considered with symptoms causing significant distress. First-line therapy is nonsteroidal anti-inflammatory drugs (NSAIDs) (Table 69-3). To maximize pain relief, NSAIDs should be taken before or as soon as menstruation begins, and the dosing schedule should be followed closely. Typically NSAIDs are needed for 2 to 3 days. If NSAIDs fail to provide adequate relief, CHCs or long-acting reversible contraceptives (LARCs) may be added.
Prescription Ibuprofen 400 mg PO qid Naproxen 500 mg PO stat then 250 PO to 500 mg PO bid Mefenamic acid 500 mg PO stat then 250 mg qid or 500 mg
LNG, Levonorgestrel; NSAIDs, nonsteroidal anti-inflammatory drugs.
These contraceptives may be first-line therapy, depending on need for pregnancy prevention.