TEENAGE GIRLS AT RISK FOR HEAVY MENSTRUAL BLEEDING AFTER CHEMOTHERAPY

Cancer treatment can put teenage girls at a high risk for heavy menstrual bleeding, and their care requires the collaborative involvement of oncologists and gynecologists, according to new guidelines issued by the Committee on Adolescent Health Care at the American College of Obstetricians and Gynecologists, and published in the August issue of Obstetrics & Gynecology.

The guidelines describe options for the prevention and management of heavy menstrual bleeding in adolescents undergoing treatment for cancer. The committee notes that gynecologists can be consulted on strategies for menstrual suppression either before cancer therapy is initiated or during an episode of severe heavy bleeding.

Cancer in girls 15 to 19 years of age is rare; the annual incidence is 20 cases per 100,000 people. However, they face a high risk for heavy menstrual bleeding as a direct result of hematologic malignancies or as a secondary effect of treatment, including chemotherapy, radiation therapy, and bone marrow transplantation that induces myelosuppression and subsequent thrombocytopenia, the committee notes.

In fact, girls who are anemic from the disease or treatment face a threat from even normal menstrual blood loss. Cancer treatment can also disrupt the hypothalamic–pituitary–gonadal axis during cancer, causing anovulatory uterine bleeding.

Therapy for menstrual suppression and for an emergent episode of severe heavy bleeding "should be tailored to the patient, her cancer diagnosis and treatment plan, and her desires for contraception and fertility," the committee writes.

Options for menstrual suppression include combined hormonal contraceptives, progestin-only therapy, and gonadotropin-releasing hormone agonists.

The guidelines cite a study in which oral contraceptives containing a combination of estrogen and progesterone were effective in producing amenorrhea in women 18 to 45 years of age (Obstet Gynecol.2003;101:653-661). Most of the women who took the pill, which contained ethinyl estradiol 20 µg and levonorgestrel 100 µg, experienced light bleeding or amenorrhea after 3 months (68%) and 12 months (88%) of use. However, there are no equivalent data in the adolescent population.

Therefore, the guidelines state that "the decision to use estrogen should be tailored to the individual patient after careful, collaborative consideration of the risk–benefit ratio; thorough counseling; and a commitment to close monitoring for known adverse effects."

Patients presenting with emergent bleeding at the time of their cancer diagnosis or undergoing myelosuppressive treatment wouldn't have time to benefit fully from prophylactic menstrual suppression. Such patients will need more urgent therapy once bleeding occurs, the committee notes.

For adolescent cancer patients who present with an episode of severe uterine bleeding, the oncologist can consult with a gynecologist regarding emergent treatment to stop the bleeding. Options include hormonal therapy and antifibrinolytics; surgical management should be a last resort. The optimal therapy for treating acute bleeding has not been established, according to the guidelines.

The committee recommends that when selecting a treatment, "considerations such as current platelet count, course of treatment, time to expected nadir, risk of thromboembolism, and need for contraception should be considered."

Obstet Gynecol. 2014;124:397-401. Abstract