What is the initial treatment for dysfunctional uterine bleeding (DUB) in a teenager?

Initial Treatment for Dysfunctional Uterine Bleeding in Teenagers

Combined hormonal contraception is the first-line treatment for dysfunctional uterine bleeding (DUB) in adolescents, with progestin-only options as alternatives for those with contraindications to estrogen. 1

Understanding DUB in Adolescents

Dysfunctional uterine bleeding in teenagers is primarily caused by anovulation due to immaturity of the hypothalamic-pituitary-ovarian axis, which is common in the first 2-3 years after menarche 2. This results in irregular, heavy, and sometimes prolonged bleeding episodes that can significantly impact quality of life and lead to complications such as anemia.

Treatment Algorithm

First-Line Treatment:

1. Combined Hormonal Contraceptives (CHCs)
   • Preferred initial treatment for most adolescents with DUB 1, 3
   • Options include:
     • Combined oral contraceptives (COCs) with 20-35 μg ethinyl estradiol
     • Vaginal ring
     • Transdermal patch (with caution due to higher estrogen exposure) 1
   • Advantages: Regulates cycles, reduces bleeding, provides contraception, improves dysmenorrhea

Alternative First-Line Options (for those with contraindications to estrogen):

1. Progestin-Only Methods
   • Oral medroxyprogesterone acetate: 10 mg daily for 10 days each month for ≥3 months 4
   • Depot medroxyprogesterone acetate (DMPA) injection every 13 weeks 1
   • Levonorgestrel intrauterine device (LNG-IUD) for older adolescents 3
   • Advantages: Safe for those with contraindications to estrogen, LNG-IUD provides localized hormone delivery with minimal systemic effects

For Acute Heavy Bleeding Episodes:

1. High-Dose Estrogen Therapy
   • For severe, acute bleeding requiring rapid control 4
   • Options:
     • Conjugated estrogens IV: 25 mg IV, may repeat in 6-12 hours if necessary 5
     • High-dose combined oral contraceptives with taper

Adjunctive Treatments:

1. Non-Hormonal Options
   • NSAIDs (ibuprofen 600-800 mg every 6-8 hours) 3
   • Tranexamic acid (antifibrinolytic) 2, 6
   • Iron supplementation if anemia develops 3

Special Considerations

Contraindications to Combined Hormonal Contraceptives:

• History of venous thromboembolism
• Uncontrolled hypertension
• Smoking in those over 35 years
• Migraine with aura
• Active liver disease
• Breast cancer

Monitoring and Follow-up:

• Assess response to treatment after 3 months
• Monitor for side effects and complications
• Consider endometrial biopsy in patients with recurrent anovulation and risk factors for endometrial cancer 3

When to Consider Further Evaluation:

• Failure to respond to initial treatment
• Suspicion of underlying pathology
• Persistent bleeding despite adequate therapy

Pitfalls and Caveats

1. Don't delay treatment while waiting for extensive workup in otherwise healthy adolescents with typical presentation of DUB.

2. Don't overlook coagulation disorders such as von Willebrand disease, which can present similarly to DUB and is present in approximately 1% of the population 4.

3. Don't use estrogen therapy alone for long-term management due to increased risk of endometrial hyperplasia and cancer 7.

4. Don't forget to screen for eating disorders, excessive exercise, or stress which can contribute to anovulation and abnormal bleeding.

5. Don't neglect patient education about normal menstrual patterns and expected treatment outcomes to improve adherence and satisfaction.

By following this structured approach to treating DUB in adolescents, clinicians can effectively manage symptoms, prevent complications, and improve quality of life for teenage patients experiencing this common condition.