Sometimes, providing parents with accurate information about the safety of oral contraceptives, emphasizing that currently available oral contraceptive preparations contain lower doses of estrogens and progestins than those used in the 1960s and 1970s, and emphasizing the hormonal rather than contraceptive function may not be persuasive. In such cases, cyclic progestins are an alternative. A systematic review of the use of combination hormonal therapy versus progestins alone for the treatment of anovulatory bleeding found a paucity of evidence supporting the efficacy of one management regimen over another (97). Medroxyprogesterone acetate, 5to 10 mg/day for 10 to 13 days every 1 to 2 months, prevents excessive endometrial buildup and irregular shedding caused by unopposed estrogen stimulation. This therapy should be reevaluated regularly and accompanied by oral administration of iron. Eventual maturation of the hypothalamic–pituitary–ovarian axis usually will result in the establishment of regular menses unless there are underlying conditions such as hyperandrogenism.
Moderate Patients who are bleeding acutely but in a stable condition and do not require hospital admission will require doses of hormones that are higher than those in oral contraceptives to effectively stop anovulatory bleeding. An effective regimen is the use of combination monophasic oral contraceptives (every 6 hours for 4 to 7 days). After that time, the dose should be tapered or stopped to allow shedding of the dyssynchronous endometrium and withdrawal bleeding. With this therapy, the patient and her parents should be given specific written and oral instructions warning them about the potential side effects of high-dose hormone therapy—nausea, breast tenderness, and breakthrough bleeding. The patient should be instructed to call with any concerns rather than discontinue the pills, and she must understand that stopping the prescribed regimen may result in a recurrence of heavy bleeding. Both the patient and her mother should be warned to expect heavy withdrawal ﬂow for the first period. It will be controlled by the institution of combination low-dose oral contraceptive therapy, given once daily and continued for three to six cycles, to allow regular withdrawal ﬂow. If the patient is not sexually active, the pill may be discontinued after the recommended course of therapy and the menstrual cycles may be reassessed.
Emergency Management The decision to hospitalize a patient depends on the rate of current bleeding and the severity of any existing anemia. The actual acute blood loss may not be reﬂected adequately in the initial blood count but will be revealed with serial hemoglobin assessments. The cause of acute menorrhagia may be a primary coagulation disorder; thus, measurements of coagulation and hemostasis, including screening for coagulopathy, should be performed for any adolescent patients with acute menorrhagia, as noted above in the recommendations of an international panel (81). Von Willebrand disease, platelet disorders, or hematologic malignancies can cause menorrhagia. Depending on the patient’s level of hemodynamic stability or compromise, a blood sample can be analyzed for type and screen. The decision to transfuse must be considered carefully, and the benefits and risks should be discussed with the adolescent and her parents. Generally, there is no need for transfusion unless the patient is hemodynamically unstable.
In patients who, by exclusion, are diagnosed as having anovulatory bleeding, hormone therapy usually makes it possible to avoid surgical intervention (dilation and curettage [D&C], operative hysteroscopy, or laparoscopy). A patient who is hospitalized for severe bleeding requires aggressive management as follows: 1.
After stabilization, when appropriate laboratory assessment and an examination established a working diagnosis of anovulation, hormonal management will usually control bleeding.
2.