Community Hospital East Family Medicine Residency, Indianapolis, Ind (Dr. Jordahl-Iafrato); University of Arizona College of Medicine, Department of Obstetrics and Gynecology, Tucson (Dr. Reed); COPE Community Services, Inc., Tucson, Ariz (Dr. Hadley); University of Arizona College of Medicine, Department of Family and Community Medicine, Tucson (Dr. Kolman) Mjordahl-iafrato@ecommunity.com
The authors reported no potential conflict of interest relevant to this article.
Information on treating other PCOS-related symptoms (acne, hirsutism) is available from many sources29; these treatments do not typically help the patient’s AUB, however, and are therefore not addressed in this article.
›Anovulatory bleeding. In adolescence, the most common cause of AUB is anovulation resulting from immaturity of the hypothalamic–pituitary–ovarian axis. During anovulatory cycles, the imbalance of estrogen and progesterone creates a fragile endometrium, leading to unpredictable bleeding and irregular cycles. Other less common causes of AUB, such as ovarian or adrenal tumor, should be considered in adolescents who have hirsutism but do not meet the criteria for PCOS.5
Endometrial dysfunction as the cause of abnormal uterine bleeding stems from aberrations in biochemical pathways— making it difficult to confirm by lab analysis or histology.
When seeing an adolescent for evaluation of AUB, be aware that emotional barriers might be present that make it difficult for her to talk about menses and sexual activity. Be patient and normalize the patient’s symptoms when appropriate. Pelvic exam can be deferred, especially in adolescents who have not yet had vaginal intercourse. When AUB occurs in an adolescent and the cause is thought to be immaturity of the hypothalamic–pituitary–ovarian axis, there is no need for laboratory testing or imaging studies, other than excluding hypothyroidism and pregnancy as the cause.
Oral contraceptives, NSAIDs, tranexamic acid, and the LNG-IUD are all options for treating patients who have anovulatory bleeding4,5 (TABLE 3). An OC has a major advantage for adolescents because it alleviates other complaints related to adolescent hormonal changes, such as acne, and provides contraception when taken on a regular basis.
Alternatively, the LNG-IUD has the benefit of ease of use once inserted, while still providing the added benefit of contraception. In women who have not yet had vaginal intercourse, an intrauterine device might not be the first choice of treatment, however, and should be prescribed only after discussion with the patient. For both OCs and the LNG-IUD, myths surrounding the use of these medications must be addressed with the patient and, if she is a minor, her parents or guardian.32
