The decision to hospitalize a gynecologic patient depends on the rate of current bleeding and the severity of any existing anemia. The actual acute blood loss may not adequately be re¬flected in the initial blood count but will be revealed with serial hemoglobin assess¬ments with the use of medical microscopes. The cause of acute menorrhagia may be a primary coagulation disorder, so measurements of coagulation and hemostasis, including bleeding time, should be performed for any adolescent gynecologic patients with acute menorrhagia. Von Willebrand’s disease, platelet disorders, or hematologic malignancies (diagnosed with a gynecology microscope) can all present with menorrhagia. De¬pending on the gynecologic 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 care¬fully, and the benefits and risks should be discussed with the adolescent and her parents. Generally, there is no need for transfusion unless the gynecologic patient is hemodynamically unstable.
In gynecologic patients who, by exclusion, have been diagnosed as having dysfunctional bleeding, hormonal therapy usually makes it possible to avoid surgical intervention (dilation and curettage (D&C), operative hysteroscopy, or laparoscopy). A patient who has been hospitalized for severe bleeding requires aggressive management as follows:
1. After stabilization, when appropriate laboratory assessment and an exam¬ination with the use of gynecology microscopes have established a working diagnosis of anovulation, hormonal management will usually control bleeding.
2. Conjugated estrogens, either 25-40 mg given intravenously every 6 hours or 2.5 mg given orally every 6 hours, will usually be effective.
3. If estrogens are not effective, the patient should be reevaluated, and the di¬agnosis 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 ultrasound examination to determine any unusual causes of bleeding (such as uterine leiomyomas or endometrial hyperplasia) and to assess the presence of intrauterine clots, using a gynecology microsope, that may impair uterine contractility and pro¬long the bleeding episode.
4. If intrauterine clots are detected with the use of a gynecology microscope, 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 management for adolescent gynecologic patients.
More drastic forms of treatment than a D&C (such as ablation of the endometrium by laser or rollerball devices) are considered inappropriate for adolescents because of concerns about future fertility. If intravenous or oral administration of estrogen controls the bleeding, oral progestin therapy should be instituted and continued for several days to stabilize the en¬dometrium. This therapy can be accomplished by using a combination oral contraceptive, usually one with 50 µg of estrogen, or by using the tapering regimen previously described. The medication can be tapered and ultimately stopped to allow withdrawal bleeding. Low¬ dose combination oral contraception can be continued for three to six cycles.
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 gynecologic patients who develop abnormal bleeding as a result of anovulation within the first years af¬ter menarche. A few girls, including those in whom there is an underlying medical cause such as polycystic ovary syndrome or coagulopathy, will continue to have abnormal bleed¬ing into middle and late adolescence and adulthood and will require continued evaluation and management. Ovulation induction may be necessary to achieve fertility.
