DUB - Rx in Adolescents:
- Preferred:
Micronized oral progesterone (200 mg) is prescribed once per day for the first 12 days of each calendar month.
Other forms of contraception must be used during this time, as progestin only do not reliably prevent ovulation.
If bleeding occurs during the progesterone course, the patient should discontinue progesterone and allow menses to occur. Bleeding usually begins two to three days after the last dose of progesterone, but may be delayed for up to one week. If the patient does not have menses within one week after the last dose of progesterone, exogenous hormones should be discontinued and an endocrinology evaluation initiated. The evaluation typically includes follicle stimulating hormone, luteinizing hormone, prolactin, dehydroepiandrosterone sulfate, free and total testosterone, thyroid stimulating hormone, and fasting insulin and glucose to evaluate potential disorders of the hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome, and the metabolic syndrome.
Alternative:
- oral medroxyprogesterone (10 mg per day for the first 10 to 12 days each month)], or norethindrone acetate (5 mg per day for the first 10 to 12 days each month)
Currently bleeding — Patients who have complaints of heavy bleeding may have a better response to oral contraceptives (OCs) that have a combination of estrogen and progestin rather than to progestin-only preparations, as estrogen provides hemostasis.
Monophasic OCs (ie, pills that contain the same dose of estrogen and progestin in each of the hormonally active pills) with a minimum of 30 mcg ethinyl estradiol should be used in order to ensure a sufficient amount of estrogen is provided to prevent breakthrough bleeding.
Monophasic.
- Yaz 24, Yasmin 28, Microgestin 1/20 28),
- OC pills be taken three times per day until the bleeding ceases (usually within 48 hours) and then tapered to twice daily for five days, and then decreased to once daily to complete 21 days of hormone therapy.
If bleeding recurs when the dose is decreased to once per day, twice per day dosing may be necessary for the full 21 days
Patients should continue therapy for three to four months, after which hormonal therapy can be discontinued to determine whether a normal menstrual pattern has been established
General Princiiples: Before starting Rx.
-Pregnancy (including ectopic pregnancy) and pelvic infections should be excluded before treatment is initiated
Additional evaluation and consultation should be obtained if bleeding cannot be controlled despite hormonal therapy
All adolescents treated for DUB should maintain a menstrual calendar to monitor subsequent episodes of DUB as well as response to therapy.
All patients with DUB are at risk for iron deficiency anemia and should be monitored and treated accordingly.
Long-term monitoring and follow-up are necessary to prevent the potential sequelae of DUB (eg, anemia, infertility, endometrial cancer).
Severe DUB
Combination OC pills — Therapy typically includes a monophasic combination OC pill with 50 mcg estradiol and 0.5 mg norgestrel (eg, Ovral®m Ogestrel® administered according to various schedules:
The schedule we prefer is estradiol (50 mcg)/norgestrel (0.5 mg) every four hours until the bleeding subsides (usually within 24 hours), then four times per day for four days, then three times per day for three days, then two times a day for two weeks.
An alternative schedule uses estradiol (50 mcg)/norgestrel (0.5 mg) every four hours until the bleeding stops (usually within 24 hours), then every six hours for 24 hours, then every eight hours for 48 hours, then twice per day to complete a 21-day course of hormones.
Addition of intravenous conjugated estrogen therapy and/or aminocaproic acid discussed below, should be considered if the bleeding is not controlled within 24 hours.
Progestin-only — For patients who can take oral medications, but in whom high-dose estrogen is contraindicated (eg, arterial or venous thromboembolic disease, estrogen-dependent tumors, and hepatic dysfunction or disease), one of the following progestin-only regimens may be tried:
Norethindrone acetate (5 to 10 mg), or
Micronized progesterone (200 mg)
Patients should be instructed to take one pill every four hours until the bleeding stops. Once the bleeding stops, they can take one pill four times a day for four days, then three times a day for three days, then twice a day for two weeks.
Premarin (25 mg IV every four hours for up to 24 hours).
No more than six doses should be administered. Because pulmonary embolism is a potential complication of intravenous estrogen therapy.
As with any high dose estrogen treatment, antiemetics 2.5 to 25 mg per rectum) should be prescribed one hour before each dose to alleviate side effects of nausea and vomiting.
Monophasic, ethinyl estradiol, 35 mcg PO daily, 4:3:2.
1 PO qid x 4 days
1 PO tid x 3 days
1 PO bid x 2 days
1 PO qd, until done, withdrawal bleeding.
Antiemetic reqd w/this regimen