OJHAS Vol. 7, Issue 1: (2008
A Study To Evaluate The Aetiological Factors And Management of Puberty Menorrhagia
Associate Professor, NRS Medical College, Kolkata;
Assistant Professor, NRS Medical College, Kolkata;
Consultant gynaecologist, Dhulian Govt.Hospital, West Bengal;
Pranab Kumar Biswas,
Assistant Professor, NRS Medical College, Kolkata.
Address For Correspondence
BE-177, Salt Lake,
Sector-1, Kolkata-700 064,
Roychowdhury J, Chaudhuri S, Sarkar A, Biswas PK. A Study To Evaluate The Aetiological Factors And Management of Puberty Menorrhagia.
Online J Health Allied Scs. 2008;7(1):5
Submitted Jun 2, 2007; Suggested
revision Jan 2, 2008; Resubmitted Mar 11, 2008; Published:
Apr 10, 2008
This study aims to evaluate the incidence, clinical presentation,
etiological factors and treatment outcomes of the patients suffering
from puberty menorrhagia.
65 patients with puberty menorrhagia attending the outpatient as well
as indoor department of NRS Medical College, Kolkata during the period
from February, 2005 to July,2006 were included in the study. They were
prospectively analysed to assess the aetiological factors and the outcome
of treatment required to manage these cases.
– The incidence of puberty menorrhagia was 9.6% in our study.
40%s patients had menarche between 12-13 years. 61.6% had anovulatory
dysfunctional uterine bleeding(DUB). 15.4% had hematological causes.
Hypothyroidism, endometrial tuberculosis, polycystic ovarian disease
were other important causes. 40% were relieved with tranexamic acid,
26% required hormone treatment and 35.3% received blood transfusion.
DUB is the cause of menorrhagia in most of the cases .Medical treatment
is mostly effective while surgical procedures are limited to few specific
Puberty menoorhagia, Anovulation, Hematological disease, Polycystic
defined as the period during which secondary sex characters begin to
develop and the capability of sexual reproduction is attained. Puberty
menorrhagia is defined as excessive bleeding in amount (>80ml) or
in duration(>7days) between menarche and 19 years of age.1
Menarche is one of the most important events in life of adolescent girl. Although
mechanisms triggering puberty and menarche remain uncertain, they are
dependent on genetics, nutrition, body weight and maturation of the
hypothalamic pituitary- ovarian (HPO) axis. The complete maturation
of the axis may take up to 2 years.1
a quarter of population in developing countries comprises girls below
20 years.2 In India, children under 15 years of age constitute
about 40% of population.3 Menstrual disorders affect
75% of adolescent females and are a leading reason for visit to physicians.4
During this period, it is common for adolescents to present with complaints
of menstrual irregularities Postmenarcheal cycles are initially anovulatory.
Without ovulation estrogen effect is unopposed by endogenous progesterone
resulting in endometrial proliferation, with eventual excessive menstrual
bleeding. Thus in a developing country, like India , puberty menorrhagia
is a fairly common gynecological disorder in adolescence and
sometimes it invites life threatening event. This study was conducted to find out
incidence, causes of pubertal menorrhagia, its complication and role
of conservative therapy.
A total of
65 young girls from the age of menarche to 19years with history of excessive
bleeding per vagina attending outdoor patient department or admitted
in the indoor department of Obstetrics and Gynecology, Nilratan Sircar
Medical College and Hospital, Kolkata were included for the study.Blood loss
during menstruation was considered excessive if (i) the
girl had persistence of menstruation of more than seven days or/and
(ii) if there was history of passage of clots and the girl had pallor
and hemoglobin 10 gm% or less. The study was carried out from 1st February, 2005 to 31st
July 2006. A detailed history regarding age, socioeconomic status,
birth incidents, milestones of her growth, pubertal developments, onset
of thelarche, pubic and axillary hair development, growth pattern, and
menarche was noted. The presenting complaint with onset, duration and
amount of blood loss were noted in details. Enquiries were made about
menstrual interval, duration of bleeding, passage of clots, number of
pads required daily. The medical history included history of
recent weight gain or loss, any voice changes, tuberculosis, endocrine
disease like diabetes, thyroid disorder, any cardiac, renal and hematological
disorders. Past surgical history was explored for any complication especially
for any excessive bleeding .Personal history included history
of any drug intake specific for any disease or which had bone marrow
toxicity. Sexual behavior, any history of trauma or abortions
were also noted. Family history was taken in details regarding
presence of any disease like tuberculosis, diabetes, thyroid disorders,
The physical examination
included calculation of height, weight and BMI of the individual. Pallor,
icterus, signs of malnutrition for any vitamin deficiency was noted. Neck vein,
neck glands, gum bleeding along with pulse, blood pressure
and temperature were noted. Abdominal palpation was done to find hepatosplenomegaly,
ascites and any other abdomino- pelvic mass in the lower abdomen. Skin
was noted for any purpuric spots. Tenderness in sternum and other bony
areas were seen along with presence of any joint swelling. Obese patients
were examined for any signs of acne, hirsutism and features of hyperandrogenism.
Secondary sex characters, like breast development, axillary and pubic
hairs were inspected. Gynecological examination included inspection
of the vulva and if the hymen appeared intact, vaginal examination was
avoided; instead, a bimanual rectal examination was done to palpate
the pelvic mass for these young girls. Speculum and per vaginal examination
was done for those patients who were married.
for investigations to be carried out was made. Some of the investigations
were done routinely in all patients which include a) estimation of hemoglobin,
total and differential count, platelet count and peripheral blood smear
examination b)bleeding time, clotting time, prothombin time, activated
partial prothombin time, platelet aggregation study c) endrocrine evaluation
like estimation of blood sugar, thyroid hormone status, luteinising
hormone, follicular stimulating hormone, fasting insulin and prolactin
d) ultrasonography of abdomen and pelvis(e) Serial folliculometry
to assess ovulation status Some of the investigations were done in selected
patients which include a) chest X-ray, mantoux test was done in suspected
cases of tuberculosis b) menstrual blood for DNA PCR examination of
Mycobacterium tubercular antigen and endometrial study was done in a
few selected cases c) bone marrow examination, serum ferritin and hemoglobin
electrophoresis having hematological problem d) Examination under anaesthesia
and laparoscopy for diagnosis of any pelvic masses.
protocol was followed on the basis of early diagnosis of the underlying
causes. Menstrual calendar was maintained in all patients. Clinical
assessment was done to assess the amount of blood loss or whether the
patient is in shock or having hypovolemia. Prostaglandin synthetase
inhibitors like Mefenamic acid, antifibrinolytic drugs like Tranexamic
acid were used as a first line of drugs during the days of menstruation
for control of blood loss. Hormones like oral contraceptive pills, progestins
were prescribed in cases not responding to nonhormonal therapy. Anaemia
was corrected by oral haematinics or blood transfusion in consultation
with haematologist. Specific treatment for correction of haematological
disease, thyroid disease, tuberculosis, surgery for organic disease
were carried out. Importance was given to provide full nutritional,
physical and psychological support to the young girls.
follow up of these patients were done by maintaining menstrual calendar,
clinical examination and by monitoring therapeutic response.
Total 65 patients
with puberty menorrhagia were analyzed for the study. Amongst them 41(61.5%)
were treated in the outpatient department. The rest 25 (38.4%) needed
admission due to severe bleeding. Thity one patients( 31/65 ;47.7%)
with menorrhagia were between 11 to 13 years of age, close to the age of
menarche. Sixty nine percent (69.2% ) patients belonged to low middle
class with the monthly family income of Rs.500 to Rs.3000.
Thirty (30/65; 46.15%) patients in this study had BMI less than 20
whereas seven (7/65; 10.8%) had BMI more than 25.
Table 1: Age at menarche
Age of Patients
No. of patients
10 -11 yrs
11 -12 yrs
The age of
menarche is shown in Table I. Twenty six (40%) of these patients had
menarche between 12-13 years and 23(35.4%) of them started menstruation
after 13 years. The majority of them (62/65; 95.4%) had development
of stage IV Tanner secondary sex characters. 37(37/65; 56.9%) patients
had menorrhagia of less than 6 months of duration and 15(15/65; 23.1%)
were suffering for more than 1year. Twenty-nine (29/65;44.6%)
patients had hemoglobin level of 10gm/dl or less (Table II).
Table 2: Hemoglobin percentage of the patients
No. of patients
7- 10 gm/dl
factors are shown in Table III. Out of the 10 haematological cases 6(6/10;
60%) were ITP cases and rest one each (10%) were hypoplastic anaemia,
Bernard Soulier disease and congenital afibrinogenemia and Von Willebrand
disease . Forty (40/65;61.5%) patients had anovulatory dysfunctional
bleeding which was diagnosed by serial folliculometry on ultrasonography(
Table IV). The patients whose age of menarche was less than 13years
developed ovulatory cycles earlier (57.69%) than patients whose age
of menarche was greater than 13 years(35.71%).
Table 3: Etiological
factors of puberty menorrhagia
No. of patients
Table 4: Anovulatory
menstrual cycles in puberty menorrhagia
of patients with age at menarche
No. of cases
Table 5: Management of Puberty Menorrhagia
Type of management
Number of patients
Antikoch’s -1& Thyroxine-6, ITP-6, Bernerdsoulier’s disease-1, Afibrinogenemia-1)*
* Alongwith specific treatment
these patients were also treated with progesterone and tranexamic acids.
of patient with puberty menorrhagia is shown in Table V. Twenty
six (26/65;40%) of these patients responded well to iron and 3-5 days
course of Tranexamic acid in the dose of 1-2gm daily. Twelve (12/65;18.4%)
patients responded with oral progesterone for 6-12cycles and 5(7.6%)
showed good response with oral contraceptives. All 6 hypothyroid patients
were treated with L-thyroxine. There were 6 ITP patients who were treated
with prednisolone with excellent response. Out of them one patient had
under gone splenectomy, two patients received platelet transfusion .Four
patients received oral medroxyprogesterone from day 5 to day 25 of cycle
for three cycles. Iron supplementation was given in all patients .In
one patient steroid was stopped and her platelet count remained normal.
Rest of the patients were on oral prednisolone therapy.
and curettage was done in 4(4/65; 6.15%) cases for disturbed pregnancy,
tuberculosis and intractable menorhagia. Specific surgical procedure
like polypectomy and myomectomy were required in 2(2/65; 3.1%) patients.
Blood component transfusion was given in 23(23/65; 35.4%) patients.
is the span of human growth extending from immaturity of childhood to
the physical and psychological maturity of adulthood. Mehotra5 in their series
found 10% of their adolescent patients suffering from menorrhagia. The
present study shows an incidence of puberty menorrhagia as 9.6% among
624 adolescents during the study period.
age of menarche is 12.5 years in India.6 In
this study 40% of patients had menarche between 12 and 13 years
and 35.5% had menarche after 13 years.
found that majority of the patients of puberty menorrhagia belonged
to lower socio economic group .This study also revealed 55% of our patients
belonged to rural family and 69.2% came from lower socio economic group.
Osler7 argued that the critical body weight must be 47.8
kg for menarche .The study shows that 46.6% of patients were between
40 and 50 kg of weight and 95.4% suffering from menorrhagia had tanners
stage 4 of breast and pubic hair development. Rao1 reported
the requirement of blood component transfusion to be 37% in treating
cases of puberty menorrhagia.1 In our study the requirement
of blood transfusion was 35%.
In the present
study 56.9% of patients had duration of the disease for less than
six months and 15% developed menorrhagia at menarche. Rao1
also observed 62% of their patients had these menstrual disorders of
less than 6months duration.1
95% of cases of anovulation are due to the immaturity of HPO axis.8
These adolescents lack the positive feedback mechanism necessary to
initiate an LH surge and subsequent ovulation despite normal follicular
estrogen level. Chaudhuri et al,9 found 71% of their
patients suffered from dysfunctional uterine bleeding. In our study
61.5% of the patients had documented anovulation .
Of Obstetrician and Gynaecologist,1999 10 recommended tranexamic
acid and mefenamic acid as first line drugs for women with menorrhagia
who either do not require contraception or prefer non hormonal treatment.
26 patients (40%) in this study group responded well with use of tranexamic
and mefenamic acid during menstruation along with oral iron therapy.
can be used cyclically in two different treatment Protocols – as short
course during luteal phase and a relatively longer course lasting 21
days from day 5 of cycle. In the present study 12(18.4%) patients received
oral progesterone therapy. Norethisterone was used from day 5 to day
25 of cycle for 3 cycles. It rapidly increased the hemoglobin level
and decreased the menorrhagia. In the present study 5(7.6%) patients
responded with oral Contraceptive pills. Tranexamic acid was used with triphasic
oral pills in 17.1% of cases and with progestogens in 8.5% cases.1
most common cause of abnormal bleeding in adolescents is coagulation
disorders. Claessens and Cowell,1981 11 in a 9 year
review, examined all admissions at a children’s hospital for
acute menorrhagia and determined that 19% were the
result of primary coagulation disorder. The present study shows hematological
disorders to be present in 15.3 % of cases. Thrombocytopenia which
was noted in 9.2 % (6/ 65) of patients was found to be the commonest
haemtological disease in our study (6/10). In both cases of hypofibrinogenemia
and Bernard Soulier syndrome, the patients presented with menorrhagia
since menarche. Congenital hypofibrinogenemia is an autosomal recessive
disorder where clotting factor 1 is lacking and it results from consanguineous
marriage. In our patient she had profuse menorrhagia which was controlled
by fresh blood cell transfusion and cyclical progesterone.
Soulier syndrome (BSS), studies of platelets reveal a quantitative and
qualitative abnormality of the membrane GPIb / IX /V complex in platelets
and macrophages. Menorrhagia is of early onset. Defects in three genes
give rise to the typical clinical features and platelet anomalies associated
with BSS. This is due to the multi-subunit nature of the affected GPIb/IX/V
receptor. The main function of the GPIb/IX/V complex is to ensure normal
primary hemostasis by initiating platelet adhesion at sites of vascular
injury. Adhesion is brought by its binding to von Willebrand factor,
itself captured from plasma by subendothelial collagen. Defects are
due to mutations in GPIbA (20 mutations), which is the largest
subunit and bears the von Willebrand binding site, in GPIbB (16 mutations) and in GP9 (11 mutations).12
One patient in our series had Bernard
Soulier variant type of disorder. On peripheral smear her platelets
were large .Small amount of immunologically detectable GPIbIX protein
was detected by flow cytometry. She was prescribed Oral iron supplementation, Tranexamic acid during menstruation. Subsequently oral progesterone
was prescribed from day 5 to day 25 of menstruation to get relief of
is associated with menorrhagia. It is probably due to estrogen
break through bleeding secondary to anovulation. Defects in haemostasis
has been demonstrated due to decreased levels of factor VII,
VIII. IX and XI.13
In the present
study 6 patients (9.2%) were found to be hypothyroid. They responded
to thyroid supplementation.
ovarian syndrome(PCOS) is an association of hyperandrogenism
and chronic anovulation in women without any specific disease of adrenal
or pituitary and is one of the most common endocrine disorder. Overall,
60-85% of patients with PCOS demonstrate overt menstrual dysfunction
primarily oligomenorrhoea although 5% may demonstrate polymenorrhoea.14
Chronic anovulation leads to endometrial hyperplasia due to chronic
estrogenic stimulation. Rao1found 2.8 % of the cause
of puberty menorrhagia were due to polycystic ovarian disease.1 The present study shows that 3.07%(2/65) of puberty menorrhagia was
due to polycystic ovarian disease. Diagnosis was confirmed with
altered day 2 LH & FSH ratio, features of hyperandrogenism and USG
diagnosed polycystic ovaries. Both of them were prescribed OCP
for 3 months. The cycle regularized and menstrual bleeding became normal.
of pregnancy complications like miscarriage must be excluded as a cause
of abnormal uterine bleeding in adolescents.15 The present
study shows pregnancy related complications in 4.6 % of patients. Although
rare, uterine pathology, such as polyps and fibroids, may lead to abnormal
bleeding.15 The present study shows two patients(3.1%,) had
Rao, 2004 found
that genital tuberculosis in 5.7 % of patients in patients of puberty
menorrhagia1.In the present study only one patient was found
to have endometrial tuberculosis(1.5%). Diagnosis was made by menstrual
blood PCR study for tubercular antigen. It was positive. She was treated
with antitubercular drugs along with tranexamic acid during menstruation.
Use of certain
medications such as hormonal treatment like depomedroxyprogesterone
acetate, non steroidal anti-inflammatory agents like aspirin, anticoagulants
like heparin, coumarin, digitalis can cause irregular menstrual bleeding.16 The
present study shows only one patient on anticoagulants due to open heart
surgery developed menorrhagia (1.5%) and menstrual cycle was restored
with reduction of the dose of anticoagulant and use of concurrent tranexamic
In the follow-up
of these patients 43(66.2%) were cured with therapy and normal cycle
was restored. Rest were controlled on continued treatment.
- Rao S, Pawar V, Badhwar
VR, Fonseca MN. Medical intervention in puberty menorrhagia. Bombay
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- Osler DC, Crawford JE. Body composition at menarche: the Frisch-Revelle
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- Kim MH. Dysfunctional uterine bleeding. In Copeland LJ, Jarrel JF. (Ed). Text book of gynaecology. 2nd ed. 2000. p-533-540