ORIGINAL ARTICLE J Nepal Med Assoc 2010;49(178):112-6

Puberty Menorrhagia Requiring Inpatient Admission

Khosla AH,1 Devi L,1 Goel P,1 Saha PK1
1
Department of Obstetrics & Gynaecology, Government Medical College and Hospital, Chandigarh, India.

ABSTRACT

Introduction: Puberty menorrhagia is a significant health problem in adolescent age group and severe
cases may require admission and blood transfusion. Aim of this study was to evaluate the causes,
associated complications and management of puberty menorrhagia.

Methods: Hospital records of all patients of puberty menorrhagia requiring admission were analyzed
for etiology, duration since menarche, duration of bleeding, investigation profile and management.

Results: There were 18 patients of puberty menorrhagia requiring hospital admission. Etiology was
anovulatory bleeding in 11 patients, bleeding disorders in five which included idiopathic
thrombocytopenia purpura in three and one each with Von-Willebrand disease and leukemia. Two
patients had hypothyroidism as the cause. Fourteen patients presented with severe anaemia and
required blood transfusion. All except one responded to oral hormonal therapy.

Conclusions: Puberty menorrhagia can be associated with severe complications and requiring blood
transfusion. Although most common cause is anovulation but bleeding disorder, other medical
condition and other organic causes must be ruled out in any patient of Puberty menorrhagia.

Key Words: Anovulation, bleeding disorder, puberty, menorrhagia ,anaemia

Correspondence:
Dr. Pradip Kumar Saha
Department of Obstetrics and Gynaecology
Government Medical College and Hospital
Sector 32, Chandigarh – 160 030, India.
Email: pradiplekha@yahoo.co.in
Phone: 91-171-2645262

JNMA I Vol 49 I No. 2 I Issue I178 I APR-JUN, 2010 112

coagulation disorders and leukemia ankle jerk. analysis with the objective to find out the incidence. bradycardia and delayed mucocutaneous bleeding. etiology and role of conservative management in the puberty Fourteen patients (77%) presented with severe anaemia at menorrhagia.9% > 16 03 of admissions for adolescent girls. Five patients (27%) were diagnosed with bleeding First episode 08 disorders. The baseline was started. duration of bleeding luteinizing hormone (LH). blood grouping and typing and transabdominal ultrasonography (USG). age of menarche. In all cases hyperandrogenemia and no further investigations were done to it is mandatory to exclude pregnancy. 10 – 12 04 RESULTS 13 – 14 04 15 – 16 07 There were 18 patients with puberty menorrhagia requiring indoor admissions among 106 making an incidence of 16. Fourteen patients < 6 months 02 presented with history of menorrhagia since less than six months 6 months – 1 year 08 and eight patients required admission at first episode.5 gm% . complete blood count. thyroid function test. Table 1. Duration of Menarche was less than one year in 10 patients. Most of the patients (83%) were in the age group of 11-16 years. complication. duration of menarche. past and was controlled on OCPs and thyroxin replacement therapy family history of bleeding disorders. Duration of menorrhagia cases.2 gm%) also had Puberty menorrhagia is defined as excessive bleeding occurring history of severe heavy menstruation since menarche. 2 I Issue I178 I APR-JUN. bone marrow etc. Patient with 4 usually become more regular and bleeding normalizes. 2010 . follicle stimulating hormones (FSH).5 gm%). Chandigarh from January 2002 Tranexaemic acid was used in six cases along with to December 2005. cold intolerance. investigation included exclusion of pregnancy. coarse In persistent abnormal bleeding and in patients with dry skin. Puberty Menorrhagia Requiring Inpatient Admission INTRODUCTION disease. Data was collected from medical records hormonal treatment. peripheral smear. hoarse voice.3 several years after menarche. Seventeen patients (94%) required multiple blood transfusions. It can pose a significant these patients had history of multiple blood transfusion at challenge to the gynecologist and can be associated with serious previous admissions in private nursing home where this diagnosis systemic complications like anaemia. history 1 menorrhagia is caused by anovulatory cycle as a result of of purpura and ecchymotic patch since childhood and received immaturity of the hypothalamic pituitary ovarian axis in the first blood transfusion twice in the past but diagnosis was made 2. Three patients showed features of polycystic ovaries should be ruled out. medical college and hospital. 3-5 hypothyroidism as the cause of menorrhagia and of which one patient also had features of overt hypothyroidism i. Two patients had 19-25% of the cases. Age. Both the patients with hypothyroidism initial bleeding duration and severity of symptoms. Beyond this time. An organic disease or malignancy in on ultrasonography but none of these patients had signs of particular is a rare cause of puberty menorrhagia. hypoproteinemia requiring was not considered. I. menstruation only after investigations in the higher institute.e. requirement of blood and component transfusion and response to therapy. Specific investigations i. A four year retrospective analysis of all patients requiring Fifteen patients received high dose oral contraceptive admission for critical puberty menorrhagia was carried in Govt pills (OCPs) and three patients responded to progestogens. Congenital acute myeloid leukemia presented with high grade fever or acquired bleeding disorder are the cause of menorrhagia in menorrhagia and bleeding from other sites. Patient suffering from leukemia of these patients. Each patient’s record was analyzed for demographic profile. were done in selected cases. admission. Age (years) No. All three patients of thrombocytopenia presented with severe anaemia (Haemoglobin 1.e. 80% of puberty presented with severe anaemia (Haemoglobin 4. Four patients required blood component in the METHODS form of platelet rich plasma and fresh frozen plasma. We carried out this rule out hyperandrogenism. Of these three patients were diagnosed with idiopathic thrombocytopenic purpura (ITP) and one patient was diagnosed 3 – 6 months 06 to be suffering from leukemia and one had von-Willebrand 6 months – 1 year 04 113 JNMA I Vol 49 I No. was referred to haematology and was given chemotherapy and menorrhagia was controlled on OCPs (Table 2). Two of between menarche and adolescence. > 2 year 03 Anovulatory dysfunctional bleeding occurred in 61% of the III. One patient of chronic Idiopathic thrombocytopenic purpura (ITP) not responding to steroids underwent splenectomy. Khosla et al. Onset of menorrhagia since menarche was present in six patients 1 year – 2 year 05 (Table 1). Patients with Von-Willebrand disease indoor admissions and blood transfusion. Duration of menarche II.

individual may become 17 66 MIU/L 01 phenotypically normal as they grow-up.e. secretion but inadequate to induce follicular maturation A population based prevalence study reported 0. 2 I Issue I178 I APR-JUN. However. Investigation all girls who presented for evaluation of menorrhagia but Haemoglobin levels in the present study 16.9 – 32% among 100% 14 women with menorrhagia.5 . at puberty for initial five years Indian literature. Bevan 13 et al found 13% incidence of thrombocytopenia among II. However. three with thrombocytopenia and one each with Von- Von-Willebrand disease 01 Willebrand disease and leukemia.3% of women with menorrhagia have an inherited I. 12 bleeding disorder as the underlying cause.5-74% in 7. Bevan et al 74 .9% of admissions over a Leukemia 01 3 10-year period were secondary to coagulopathy. Management 11 in teenagers with menorrhagia. Initial Platelet count management modalities of Von-Willebrand disease are 3 1. 2010 114 . Aetiology No.000 – 15. Our patient was managed with blood transfusion and responded to high dose of OC pills. In the present review of 18 cases of after menarche anovulation arises from lack of maturity severe puberty menorrhagia requiring indoor admission. Aetiology. III. Puberty Menorrhagia Requiring Inpatient Admission DISCUSSION Anovulatory bleeding was the cause in 50 – 74% of the patients requiring hospital admission as reported in the 2.6% had thrombocytopenia.16 Jennifer A. Saxena R et al reported 15. the recent literature reports 10.8% and ovulation. 2. Investigation. Alternative 44 MIU/L 01 therapy for individuals with Von-Willebrand disease and USG platelet function desmopressin a synthetic analogue of Normal 15 vesopressin which in intranasal form increase the 18 Polycystic ovaries 03 circulating levels of VWF and factor VIII.3 of hypothalamic-pituitary-ovarian-axis leading to immature 61% were diagnosed to be having abnormal uterine timing of LH pulse as well as increase basal levels of LH bleeding due to anovulation. Management Blood transfusion 17 Hypothyroidism as a cause for menorrhagia has been High dose OCPs 12 debated. Prentice in his review of menorrhagia states High dose OCPs + Tranexmic acid 03 that there is little evidence to link hypothyroidism with Progesterone + Tranexmic acid 03 JNMA I Vol 49 I No. A retrospective analysis Hypothyroidism 02 by Falcone et al found that 4. Incidence of dysfunctional uterine bleeding less than 80ml and the normal cycle length varies from in adolescent menorrhagia varied from 69. 10. 11. 6 varied from 17-25%. In present Anovulatory cycles 11 study five (27%) patients presented with bleeding disorder Idiopathic thrombocytopenic purpura 03 i.4 lac/mm 14 blood transfusion and high dose oral contraceptive pills. < 6 gm/dl 05 8 – 10 m/dl 02 Von-Willebrand disease is characterized by an autosomal > 10 gm/dl 01 dominant pattern of inheritance and affects approximately PTI 14 1% in the general population and 11. Unopposed estrogen stimulates endometrial prevalence of perceived bleeding symptoms including 9 growth which outgrows its blood supply and architectural menorrhagia in young healthy females.000/ mm 3 04 Because concentration of Von-Willebrand factor (VWF) TSH(Thyroid stimulating hormone) tend to increase with age.100% 02 reported two cases of type I Von-Willebrand disease 13 50% 02 among 71 girls with adolescent menorrhagia.8 25-35 days. results in anovulatory cycles. Khosla et al. These cycles are characterized by levels of FSH and LH that are sufficient Acquired and congenital bleeding disorders are second to induce follicular development and induce estrogen most common cause of menorrhagia in adolescence girls. Reported incidence support.4% prevalence of inherited bleeding disorders Table 2.10 irregular manner.15. resulting in partial breakdown and shedding in of bleeding disorder in adolescent menorrhagia in past 5.3 Normal menstrual blood loss is defined as blood loss of literature.

Kase N. Ahuja R. Owens O. Lancet. DeVore GR. Clinics of North America. Bleeding adolescent. Cowell CA. Puberty Menorrhagia Requiring Inpatient Admission 19 excessive menstrual loss. Owens D. Von- R. often in doses insufficient to correct subsequent cycle control OCPs. 91. ovarian disease. Continuation therapy is usually haematological and endocrinological problems can be recommended and may be given in the form of oral associated with puberty menorrhagia not responding to equine estrogens in the doses of 2. 35:337. Scott JC et al had quoted with addition of medroxyprogesterone acetate 10 mg incidence of menorrhagia in myxoedema patients 36% for the last seven days or in the form of OCPs. 351:485-9. Des Jardins C. Claessens EA. O’Connell BJ. 1995. Lindgren A. Stenechever MA. 1987. Obstetrics & Gynaecology blind randomized control study. Debra A. Lee CA. Sabin CA. Use of intravenous premarin 6. 2000. If the and menorrhagia many not infrequently be the presenting bleeding is not associated with severe symptoms 20 complaint. Acute adolescent menorrhagia. Willebrand disease: A rare cause of puberty menorrhagia. 44:1391-404. Treatment of common menstrual disorders. cyclic oral manifestation of the condition. Acta Obstet Gynecol Scand. The pediatrician and the sexually active 9. 1982. More 2 haematological. 7. Minjarez MD. 55:353-5. Lethagen S. A profile of adolescent girls 2. 2 I Issue I178 I APR-JUN. Aust NZ J Obstet Gynaecol. 4. 1997. Dysfunctional uterine bleeding in adolescents. Granger L. Herbst AL. Karen D. Bradshaw MD. Obstet Gynecol. study. responded to either combination oral contraceptive pills Polycystic ovaries may be temporary in adolescent or in high dose or progesterone. Am with gynecological problems. A double uterine bleeding in adolescents. 139:277-80. 59:285. REFERENCES 1. J Obstet Gynecol. 27:72. Sengupta S.e (25 mg every four hourly) is highly effective in controlling uterine bleeding 21 and is usually continued most of the cases. Falcone T. Frequency of inherited bleeding disorder in women with Comprehensive Gynaecology St Louis MD: CV Mosby. Kriplani A. Takkar D. 85:200-6. The menorrhagia associated with combination OCPs in accelerating i. Chaudhary VP. J Reprod Med. In present be excluded by appropriate evaluation especially in those study all except one responded to medical treatment. 2006. menorrhagia. 5. 10. 1998. Friberg B. 115 JNMA I Vol 49 I No. J Obstet Gynecol India. For replacement. Khosla et al. In our study all except one patients hemostasis at menstruation. Hemmings 8. until bleeding has ceased which occurs within 24 hours adolescent health care provider should be aware of in most of the cases. twice daily for one hypothyroidism respond promptly to the thyroid week followed by three weeks of regular dosing. Of three patients with anovulation who CONCLUSIONS showed features of polycystic ovaries on ultrasonography. This suggests that medroxyprogesterone acetate or nor ethinderone acetate thyroxine does have a direct effect on arterial and on 21 may be prescribed. 2010 . 2005. Dutta R. Abnormal in the treatment of dysfunctional uterine bleeding. p. gynaecologists. 3. Goswami S. Paediatricians. Medical management is effective in i. 39:761-4.5 mg for 20-25 days routine treatment. Pediatr disorders among young women: population based prevalence Clin North America. Bourque J. endocrinological or organic causes should than 93% respond to medical treatment. Orno AK. Kadir RA. 1981. 1994. none of these had features of hyperandrogenism or Adolescent menorrhagia is common condition and can hyperandrogenemia to label the diagnosis of polycystic become serious requiring admission and blood transfusion. Quiros E. Hormonal therapy remains the most Most of the cases can be explained by anovulation but effective treatment for the puberty menorrhagia. 954-5.e. Droegemuller W. may progress to full blown polycystic ovarian disease 6 with hirsutism. patients who present in menarche or are not responding Intravenous administration of conjugated equine estrogen to the treatment. Economide DL. Mishell DR.

Strickland JL. Gorver S. Hillery CA. Zimmerman TS. Moore P. 24:44-9. Ruggeri ZM. 14. Bleeding disorder: A common cause of menorrhagia in adolescent. 13. 53:234-8. 19. 1999. Bevan JA. 20. Women with von-Willebrand disease. Von Willebrand disease in children and adolescent. 1964. Edlund M. 2001. 90:2515-21. Obstet Gynaecol. 18:140-52. JNMA I Vol 49 I No. Mannucci PM. 1997. 2003. Human Pathol. Bhargava M. Desmopressin in the treatment of bleeding with menorrhagia. Prentice A. Inherited bleeding disorder in Indian women 18. 1987. Gupta PK. Scott JP. Obstet Gynecol Clin N Am. 30:321-35. BMJ. Jayasinghe Y. adolescents. Am J Pediatric Clin North America. 12. 319:1343-5. 90:161-5. Choudhary VP. Puberty Menorrhagia Requiring Inpatient Admission 11. 1996. Aus NZ J Obstet Gynaecol. J Pediatrics. Andersson O. Menstrual patterns of myxedema. disorders: In the first 20 years. 17. Am J Hematol. Bleeding disorders in teenagers presenting with Hamostaseologie. Abnormal uterine bleeding in disorders. 9:660-1. Monagle P. Scharrer I. 2 I Issue I178 I APR-JUN. Wall JW. Saxena R. 16. 45:439-43. Danath S. On the value of menorrhagia as a preductor for coagulation 21. Von Schoultz B. 2003. Malaney KW. Hemophilia. Gupta M. Scott JC. Blomback M. Werner EJ. Mussey E. 2010 116 . 1996. Montgomery RR. 2004. Von-Willebrand’s disease. 43:683-707. Gill JC. Campbell J. 2005. 138:856-61. menorrhagia. Blood. Medical management of menorrhagia. 15. Khosla et al. Kashyap R.