A 16-year-old girl comes to the emergency department with heavy vaginal bleeding for 3 days. The patient's menses have been irregular since menarche at age 14 and occur every 4-5 months; her previous menstrual period was almost 4 months ago. She has no medical problems and has had no surgeries. She does not use tobacco, alcohol, or illicit drugs. The patient is sexually active and uses condoms for contraception. Temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, pulse is 90/min, and respirations are 16/min. On pelvic examination, there is a moderate amount of blood in the vaginal vault and active bleeding from the cervical os. Bimanual examination shows a small uterus and no adnexal masses. Pelvic ultrasound reveals a small uterus with a thick endometrial stripe and normal ovaries. Urine pregnancy test is negative. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 16-year-old girl comes to the emergency department with heavy vaginal bleeding for 3 days.  The patient's menses have been irregular since menarche at age 14 and occur every 4-5 months; her previous menstrual period was almost 4 months ago.  She has no medical problems and has had no surgeries.  She does not use tobacco, alcohol, or illicit drugs.  The patient is sexually active and uses condoms for contraception.  Temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, pulse is 90/min, and respirations are 16/min.  On pelvic examination, there is a moderate amount of blood in the vaginal vault and active bleeding from the cervical os.  Bimanual examination shows a small uterus and no adnexal masses.  Pelvic ultrasound reveals a small uterus with a thick endometrial stripe and normal ovaries.  Urine pregnancy test is negative.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d999_e168_bc81_737e66f3a3b9_MD0003_00 This patient's acute abnormal uterine bleeding (AUB) is most likely due to ovulatory dysfunction and requires clinical intervention to prevent further bleeding. In adolescents, AUB is typically caused by an immature hypothalamic-pituitary-ovarian axis, resulting in anovulation and heavy, irregular bleeding. Without ovulation, there is persistent endometrial proliferation that results in heavy menses when ovulation does occur. Heavy menses is caused by exaggerated necrosis of the superficial layer of the endometrium, which eventually becomes denuded and continues to bleed due to lack of tissue stability. Initial evaluation of patients presenting with acute vaginal bleeding includes a complete blood count, pregnancy test, and coagulation studies. In hemodynamically stable patients, acute uterine bleeding may be medically managed. First-line treatment includes intravenous estrogen (conjugated equine estrogen) or high-dose oral estrogen/progestin contraceptive pills. High-dose estrogen quickly stabilizes the denuded endometrium and stops menstrual bleeding. High-dose progestins may be given to patients with contraindications to estrogen (eg, history of thromboembolism). Progestins can also stabilize the endometrial lining and prevent further proliferation, but are not as effective as estrogen. (Choices A and D) In hemodynamically unstable, anemic patients (eg, tachycardia, hypotension), a dilation and curettage and/or a packed red blood cell transfusion may be indicated. A dilation and curettage removes the endometrium to quickly stop bleeding in an acute situation. This patient is hemodynamically stable. (Choice B) High-dose gonadotropin-releasing hormone (GnRH) agonists (eg, leuprolide) create a hypoestrogenic state and are used to suppress symptoms of endometriosis and uterine leiomyoma. However, GnRH agonists do not work quickly enough to stop acute bleeding. In addition, GnRH agonists are not recommended for adolescents due to decreased bone mineral density caused by prolonged use. (Choice E) The most common inherited coagulation factor deficiencies include hemophilia A (factor VIII) and B (factor IX). Evaluation for these deficiencies is indicated in the settings of heavy bleeding and abnormal coagulation studies (eg, PT, PTT). This patient has normal coagulation studies and coagulopathy investigation is not indicated. Educational objective: In adolescents, the immature hypothalamic-pituitary-ovarian axis causes anovulation and can result in heavy, irregular menstrual bleeding. In hemodynamically stable patients, heavy vaginal bleeding is managed with high-dose oral contraceptive therapy to stabilize the endometrium and stop the acute bleeding. References: Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. (http://www.ncbi.nlm.nih.gov/pubmed/22946701)

A 16-Year-Old Girl Comes to the Emergency Department with Heavy