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Adolescents
Julie L. Strickland
Jeffrey W.Wall
Physical examination:
• Vital sign, including height and weight
• Major body system, especially skin and neurologic
system (for endocrinology and systemic disease)
• Petechial hemorhage or echymosis
• Tanner staging of breast and pubic hair (hormonal
marker)
• Excessive androgen stimulation (acne, hair growth)
Clinical Evaluation
Gynecology examination:
• Should be tailored to age and clinical situation
• Adequate time for explanation, patience, gentleness
during examination
• Speculum may not be necessary in patien who has not
initiated sexual intercourse, except heavy bleeding, pain
an gynec symptom
• If needed speculum, use a narrow, stright blade
speculum
• If suspected sexual activity, take culture
• To assess pelvic mass or pelvic anatomy abormality
perform single digit or recto abdominal exam.
Laboratory Assessment
• Pregnancy test is initial test before beginning any
assessment
• Initial evaluation
Complete blood count, differential
Platelet count
Fibrinogen
Prothrombin time
Partial tromboplastin time
Bleeding time
• If bleeding is severe/prolonged/associated w
menars/initial screen in abnormal
von Willebrand factor antigen
Factor VIII activity
Factor XI antigen
Platelet aggregation studies
Laboratory Assessment
• If there is systemic or metabolic disease:
do thyroid, adrenal, other systemic disease
test.
• If there is hyperandrogenism: check T,
DHEAS,17-OH progesteron, Gonadotropin,
Fasting insulin and glucose level
• If atipical bleeding :transabdominal USG
• If prolonged bleeding, severe
hyperandrogenism, obesity, carcinoma:
endometrial sampling
• If abnormal anatomy: transperineal USG,
MRI
Treatment
• Goal:
– To identify the source of bleeding and direct
th/
– To stop abnormal bleeding
– To help adolescent have more predictable,
manageable menstrual cycle
• If there is profuse bleeding, hypovolemic, Hb<9
g/dl resuscitation: volume expansion/ blood
product
• The most effective: hormonal therapy (93%
respond)
Treatment
• Hormonal therapy for severe, acute bleeding:
– Conj. Equine estrogen 25mg/4 h, iv
– Continue with CEE 2,5 mg (20-25 d)
– MPA 10 mg (for the last 7-10 d)
– Or followed by OC
• Antifibrinolytic therapy
• If bleeding prolonged: CEE 2,5 mg (21-25d)
followed MPA 10 mg (last 7 d) or OC
accelerated dose (2x1 for 1 week, followed
1x1 for 3 weeks)
Treatment
• For only mild symptom of menstrual
irregularity or prolonged menses:
reassurance and education is sufficient
therapy.
• For heavy, prolonged menses: add NSAID ,
antifibrinolytic
• Limited use in treatment of abnormal
bleeding:
– DMPA, LNG impregnated IUD
– GnRH agonist
– Surgical management: D&C/ Hysteroscopy
Prognosis
• Irregular, unpredictable, heavy bleeding in
adolescent occurs as result of lack of
maturation of HPO axis.
• Over the first 3-5 postmenarchal years, most
will develop regular, cyclic menses.
• If normal menses has not develop in 4 years,
the chance for normal menstrual function is
low.
• Many of these women : decreased reproductive
potential, endometrial Ca, subsequent
gynecologic surgery surgery.
Summary
• Abnormal and irregular bleeding are extremely
common in the adolescent period and can be
looked as apart of normal reproductive
development.
• It is essenstial to have a firm grasp on normal,
physiologic development of the menstrual
cycle.
• It is important to recognize the distinc needs,
goals, and development stages of adolescent
patient.
• No single therapy or approach is universal in
the diagnosis and treatment, but must be
tailored to individuals and situation.