Estrogen-progestin therapy in the form of combined oral contraceptives given as one or two pills twice a day for 5 to 7 days is typically effective within 12 to 24 hours. Alternatively, conjugated estrogens, either 25 to 40 mg given intravenously every 6 hours or 2.5 mg given orally every 6 hours, will usually be effective (98).
3.
If this hormonal therapy is not effective, the patient should be reevaluated and the diagnosis should be reassessed. The failure of hormonal management suggests that a local cause of bleeding is more likely. In this event, consideration should be given to a pelvic ultrasonographic examination to determine any anatomic causes of bleeding (such as uterine leiomyomas, endometrial polyps, or endometrial hyperplasia) and to assess the presence of intrauterine clots that may impair uterine contractility and prolong the bleeding episode. Although anatomic causes of heavy menstrual bleeding are rare in adolescents, they become increasingly common in women of reproductive age.
4.
If intrauterine clots are detected, evacuation of the clots (suction curettage or D&C) is indicated. Although a D&C will provide effective immediate control of the bleeding, it is unusual to reach this step in adolescents.
More drastic forms of treatment other than a D&C (such as ablation of the endometrium by laser or cryotherapy) are considered inappropriate for adolescents because of concerns about future fertility.
If intravenous or oral administration of hormonal therapy controls the bleeding, oral progestin therapy should be instituted and continued for several days to stabilize the endometrium. This therapy can be accomplished by using a combination oral contraceptive, usually one with 30 to 35 mg of estrogen, or by using the tapering regimen previously described. The medication can be tapered and ultimately must be stopped to allow withdrawal bleeding, which may be heavy, given an excessively built-up endometrium. Low-dose combination oral contraception once daily should be continued for three to six cycles, or longer if desired, to provide normal menstrual cycles. Manipulation of the regimen by increasing or decreasing the dose of oral contraceptives to twice a day or three times a day after the initial high dose therapy should be discouraged.
In general, the prognosis for regular ovulatory cycles and subsequent normal fertility in young women who experience an episode of abnormal bleeding is good, particularly for patients who develop abnormal bleeding as a result of anovulation within the first years after menarche and in whom there are no signs of other specific conditions. Some girls, including those in whom there is an underlying medical cause, such as PCOS, will continue to have abnormal bleeding into middle and late adolescence and adulthood and will benefit from the ongoing use of oral contraceptives to manage hirsutism, acne, and irregular periods. Ovulation induction may ultimately be necessary to achieve fertility in these individuals, although teens should be advised that they should not assume that they are infertile. Individuals with coagulopathies may benefit from ongoing oral contraceptive use, use of tranexamic acid, or intranasal desmopressin (99).
A progestin-releasing intrauterine device (IUD) can be effective in managing heavy bleeding, and may be appropriate for adolescent use (100,101). The levonorgestrel IUD is approved by the FDA for treatment of heavy menstrual bleeding in women requiring contraception and is recommended as first-line medical therapy for this group of women (102).
For patients with underlying medical conditions, such as coagulopathies, a malignancy requiring chemotherapy, or developmental disabilities, long-term therapeutic amenorrhea with menstrual suppression using the following regimens may be necessary or helpful (103): 1.
Progestins such as oral norethindrone, norethindrone acetate, or medroxyprogesterone acetate on a continuous daily basis (104).
2.