Non-Medical Management of Refractory Life-Threatening Menstrual Bleeding in the Adolescent

Abstract

Background: The causative factor in the majority of cases of adolescent heavy menstrual bleeding is anovulatory dysfunctional uterine bleeding while inherited bleeding disorders contribute to approximately 10% of cases in adolescents at our institution. The principles of initial severe menstrual bleeding management in the adolescent patient include aggressive fluid replacement, coagulopathy reversal, fibrinolytic therapy, and hormone administration. Once aggressive, standard medical management has been exhausted, interventional radiology or surgical approaches may be required to aid in stopping ongoing losses. The ultimate long-term goal of therapy in this age group is to maintain reproductive potential. We report two cases involving non-medical management which achieved bleeding cessation without, presumably, compromising fertility. Cases: Intrauterine balloon tamponade A 13-year old female with prolonged heavy menstrual bleeding and a past medical history significant for remote, cured Stage IV neuroblastoma. She received cyclophosphamide and cisplatin as part of her treatment. Diagnostic hysteroscopy identified the site of bleeding which was subsequently tamponaded with a large caliber Foley catheter. The severe menstrual bleeding resolved and hormonal therapies were weaned to a combined oral contraceptive pill (COCP). Investigations did not reveal any evidence of a bleeding disorder, and the etiology of the bleeding was thought to be due to ovulatory dysfunction secondary to previous chemotherapy. Uterine artery embolization (UAE) A 15-year old female with regular menstrual cycles presented with severe menstrual bleeding. Initial management at a regional hospital resulted in stabilization for transfer to a tertiary level pediatric hospital. Angiography with non-occlusive, selective bilateral UAE using an absorbable material (Gelfoam) was undertaken to rule out a vascular malformation and provide temporary control for hysteroscopic assessment. Diagnostic hysteroscopy confirmed the presence of a thick polypoid endometrium which was found to be secretory on sampling. The bleeding subsided and menstrual control was afforded with a COCP. There was no confounding bleeding disorder. Comments: Non-occlusive, selective bilateral UAE with an absorbable material and hysteroscopy-guided intrauterine balloon tamponade are non-destructive therapeutic modalities which should not impact on future reproductive and obstetrical outcomes. Neither of the patients presented here have attempted pregnancy so this statement still awaits confirmation. Invasive options may be considered as an adjunct to medical management in refractory cases. These cases highlight that medical therapy should be initiated early and aggressively as adolescents may remain hemodynamically stable in the face of significant blood loss and decompensation may occur rapidly.