Evaluation and management of adolescents with acute heavy menstrual bleeding: a large single institution experience Restricted; Files Only

Brown, Megan (Spring 2020)

Permanent URL: https://etd.library.emory.edu/concern/etds/vd66w0955?locale=en


Background: Heavy menstrual bleeding (HMB) is commonly reported by adolescent females. There is limited data to guide the laboratory evaluation and medical management of adolescents presenting with acute HMB.

Objectives: Characterize the ability of an electronic medical record-based institutional protocol to diagnose inherited bleeding disorders in adolescents with acute HMB, and determine the utility of conjugated IV estrogen to obtain hemostatic control within twenty-four hours. 

Methods: We performed a chart review on a retrospective cohort of menstruating females seen in Children’s Healthcare of Atlanta Emergency Department between 2017-2018 for acute HMB. Subjects had a positive screen on a modified Claire Philip Screening Tool or active bleeding. Subjects were excluded if they had a diagnosed bleeding disorder, previous work-up for a bleeding disorder, active cancer or rheumatologic disease. Von Willebrand disease (VWD) diagnosis was based on Von Willebrand factor antigen (VWF:Ag) or ristocetin cofactor assay (VWF:RCo) less than 50%. Conjugated IV estrogen treatment failure was defined as need for antifibrinolytic therapy as outlined by the institutional protocol. 

Results:  Over a 2-year period, 221 individuals were seen for acute HMB with 88 (37.9%) requiring admission and 6 (2.6%) requiring intensive care. The population was primarily African American (62%) with a median age at presentation of 14.6 years (IQR 13.0-16.6). The incidence of VWD was 7.5%, and 69% of those with VWD had low VWF levels during acute bleeding. Factor VIII, VWF:Ag and VWF:RCo were all higher during acute bleeding than at follow-up visit (p <0.005). Despite elevated levels during acute bleeding, the negative predictive value for VWD for VWF:Ag or VWF:RCo > 100% was 92.3% (CI 74.9-99.1%) and 95% (CI 75.1-99.9%) respectively. Conjugated IV estrogen stopped bleeding within 24 hours in 89% of adolescents, and no thrombotic events were identified in the following 12 months. 

Conclusion: VWD levels are elevated during acute bleeding, but testing for VWD at that time detects VWD in the majority of patients with VWD, and that conjugated IV estrogens lead to uterine hemostasis in the majority of adolescents with acute HMB, but those with bleeding disorders are more likely to require a second agent to obtain hemostasis.

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