PUBERTY MENORRHAGIA

As I have already mentioned in different paragraphs earlier, puberty signifies sexual maturity. It takes place in stages from about 10 to 15years of age; the culmination of puberty is Menarche, the start of menstrual cycle. It is now ,that a young girl becomes a woman and can reproduce. They develop breasts pubic and axillary hair and gain height. It takes some time for their menstrual cycles to mature and become regular. At this stage it also does not produce an egg every month; these cycles are called anovulatory cycles. There are many other reasons why these cycles are anovulatory. As mentioned in previous posts on menstrual cycle. The menstruation works by ,well controlled activation between three main endocrine glands Hypothalamus and Pituitary in the brain and the Ovary, this is called Hypothalamus Pituitary and Ovarian axis (HPOAXIS).Maturation of the HPOAXIS is characterised by the frequency and amplitude of secretion of GnRH(Gonadotrophin releasing ) hormone from the hypothalamus which regulates the production of FSH and LH from the pituitary. The basal FSH and LH are enough to help with the maturation of the follicle but inadequate to cause ovulation, thus resulting in anovulatoy cycles. This upsets the complex mechanism of normal menstrual cycle

This takes time to mature after menarche. This is the main physiological reason for irregular heavy periods. When this happens from menarche to 19 years of age it is called puberty menorrhagia.

HOW MENSTRUAL BLEEDING OCCURS AND STOPS

When the Oestrogen and Progesterone are withdrawn during the menstrual cycle the growing superficial layers of the endometrium start shedding, it is auto digested by a complex mechanism. The basal layer of the endometrium starts regrowing for a new cycle .With many other complex changes the blood vessels retract and the bleeding stops. There are 2 hormones secreted by the endometrium when it is disintegrating, prostaglandin PGF2 (vasoconstrictor and platelet aggregator) and PGE2 (vasodilator and week platelet aggregator) under the influence of Oestrogens and Progesterone. In normal menstruation the ratio of PGF2and PGE2 is 2:1. Together they balance the menstrual bleeding.    If there is no ovulation in absence of progesterone PGF2 decreases, PGE2 increases resulting in more vasodilatation and more bleeding hence menorrhagia.

POLYCYSTIC OVARIAN SYNDROME

The other reason for puberty menorrhagia is a condition called, Polycystic Ovarian syndrome (PCOS) This is a complex endocrine disorder of reproductive years and can occur at any age. It is estimated that at present there are about 6-10 % of women who suffer from this problem. In addition to excessive bleeding they generally have no periods, hair on the face and body, acne, pigmentation of the neck, obesity, and infertility and may have diabetes or tendency to be diabetic.

I have described this problem under a special post on PCOS early last year.

COAGULOPATHIES (BLEEDING DISORDERS)

In our bodies there are mechanisms built in, so that they come into play when we are bleeding. This is done by coagulants and cells in the blood called platelets. When this coagulation system is disturbed, people suffer from bleeding disorders.  These can be inherited or can happen by viral infections, drugs and radiation therapy. Platelet deficiency and platelet function disorders; cause menorrhagia from the start of periods.  This is often severe and often requires blood transfusion and even platelet transfusion. The other problem caused by bleeding disorders is called vonwillebrands disease. This is an inherited disease caused by a defect in vonwillebrands factor; this prevents both platelet adhesion and clotting which are both important to stop bleeding. Besides these, there are many other problems which can cause excessive bleeding, these can be pelvic infections, early stages of pelvic tuberculosis (Rare in developed countries however seen mainly in developing countries), drugs, and some intrauterine contraceptive devices, then local uterine polyps and uterine fibroids; although rare in this age group

can cause heavy bleeding .Pregnancy related complications are often a cause of excessive bleeding. In a woman who is bleeding always do a pregnancy test and make sure she is not bleeding due to some complication of pregnancy  One very important and a fairly common problem at puberty is a condition called Endometriosis. In this condition the lining of the uterus is scattered outside the uterus. This can happen in very young teenagers. This causes heavy periods, irregular bleeding and pain. In spite of years and years of research we cannot yet explain why this happens. Besides these thyroid dysfunctions a particularly underactive thyroid can also cause menorrhagia.

WHAT IS MEMORRHAGIA?

Normally it takes 4-5 days for menstruation to stop and the average blood loss is 80 mls. If it lasts for 7 days or more, a teenager soaks a tampon or a pad in less than an hour and has

to change pads during the night, passes blood clots with her menstrual bleeding and feels very tired, has anaemia then she is surely bleeding; too much.

When she presents to her doctor, she should take a proper medical and family history.  Examine her for pallor (Anaemia) any lymph nodes, abdominal examination for spleen, liver any abdominal masses e.g. a fibroid. Examine the skin for bruising (this happens with bleeding disorders), hairiness on the face and body, as can happen in PCOS.

The main tests required are blood tests for anaemia, bleeding disorders, thyroid function tests, pregnancy test endocrine tests (POCS) and pelvic ultrasound. Some special tests such as vonwillebrand factor are also required.

TREATMENTS

One has to be very sensitive and careful in treating these teens particular in some countries such as Pakistan, Egypt and other countries because of their cultural differences.  Initially non hormonal therapy is used during menstruation. Some drugs called prostaglandin synthetase inhibitors are initially used. The most common drug is called Mefaminic acid, 500 mgs followed by 250 mgms 6hrly or less for 2-3 days during bleeding time. These drugs can cause stomach upset and thrombosis problems, however they   also help with period pain. The other drugs are very effective and commonly used and are called Tranexmic acid. It is given 1-2gms per day it is a very effective. It can also be given intravenously. It is also being used for bleeding due to trauma; in fact they are using it for post partum bleeding. Anaemia also requires correction either by blood transfusion, iron transfusion or simple oral iron if it is not too bad. Hormonal treatment with progesterone is useful when the cycles are anovulatory.  This can be followed by cyclical progesterone. The simple and very easy treatment is combined oral contraceptive pill, if the woman and her family agree. In women with very profuse bleeding, when their blood volume is disturbed, they were treated by blood transfusion and intravenous equine oestrogens. 25mgms every 4 hours for 24 hours and the bleeding generally settles in 24 hours. Then Oral oestrogens can be used.  For women with vonwillebrands disease; Tranexamic acid can be used. They also respond to oral progesterone .Tranexamic acid is a relatively cheap drug and is available all round the world under different names. WHO recommends this drug as an essential medication for all emergencies round the world? Besides these treatments an intrauterine device with a hormone impregnated called levonorgestral( MIRENA)is , very useful. Once fitted inside the uterus it lasts for 5 years. A special preparation called desmopressin acetate is also very useful for vonwillebrands  disease .This is not always easily available, long term we try to manage with combined oral contraceptive pill and  tranexmic acid during period . This protects the fibrin hence helping with coagulation. If the woman has any local disease such as uterine polyp or a fibroid it is surgically treated. For POCS we give combined oral contraceptive pills.