Puberty Menorrhagia AUB :PALM COEIN

1. PubertyMenorrhagia
DR SHARDA JAIN
Dr Jyoti Agarwal

2. FIGO Classification System
AUB :PALM COEIN
Structural Functional

3. Where Adolescent AUB
is Categorized ?
A : AUB - O

4. Adolescent AUB Is like cricket Team
with All Its Menstrual Patterns
This PPT Will
Focus
on Puberty
Menorrhagia

5. PUBERTY MENORRGIA
WHAT WE MEAN BY IT ?

6. PUBERTY MENORRHAGIA –
Means bleeding lasting longer
than 7 days or exceeding 80 ml
of blood loss

7. MENSTRUAL PATTERN IN PUBERTY
MENORRHAGIA
• Soaking through pads / tampons in 1 h for 203 h in a row ?
• Passing blood clots ≥ 1 inch in diameter (“about the size of a
quarter”)?
• Using “double protection” (pad plus tampon or 2 pads
together) ?
• Flooding or gushing sensation?
• Frequent “accidents” or leaking through protection ?
• Ever diagnose with anemia?

8. ADOLECENT AUB -30 TO 40 % (2 IN 5)
PUBERTY MENORRHAGIA 20 % (1 IN 5)
PREVALENCE

9. PREVALENCE
A College of DU (college of Applied sciences ) & VATSALYA Vocational Training
centre--quiz based study of 1006 adolescents done by DELHI GYNAECOLOGIST
FORUM: 2010
 Incidence of AUB was 40 %
 Out of those who have AUB
20% had Puberty Menorrhagia.
20% had delayed periods bcz of PCOD (35 to 90 days)
Survey done during ADOLESCENT WORKSHOPS of
DGF

10. CAUSES OF PUBERTY MENORRHAGIA
Endocrinogic
• Dysfunctional uterine bleeding (immaturity of the HPO
axis)
• Polycystic ovary syndrome
• Thyroid disturbance
Hematologic
• Von Willebrand disease
• Platelet function disorder
• Connective tissue disorder (eg Ehlers – Danlos Syndrome )
Thrombocytopenia
• Hemophilia Carriage
• Cloting factor deficiencu

11. CAUSES OF PUBERTY MENORRHAGIA – cont.
Pregnancy complication
Sexually Transmitted infection / Pelvic inflammatory
disease
Medication
• Hormonal contraceptives
• Antidepressants / Antipsychotics
• Platelet inhibitors
• Anticoagulants
Trauma
Systemic illness

12. Review of literature --on Causes &
their incidence
• HPO dysfunction ( Anovulation ) 50 %
• Bleeding Disorders 20 %
• PCOD 10-15 %
• Hypothyroidism 4 %
• Genital tuberculosis 4 -6 %
• Miscellaneous ( rest )
Liver disorders
Feminizing ovariana tumors - granula cell
and theca cell tumors
Adrenal hyperplasia

13. IN PUBERTY MENORRHAGIA-ANOVULOTORY
BLEEDING, COAGULOPATHY, INFECTONS,&
COMPLICATIONS OF PREGNANCY HEAD THE LIST
REMEMBER

14. PREGNANCY
• Should always be considered ,particularly in
adolescents who may be reluctant to reveal
their sexual history.
• It is important to emphasize that the most
common cause of sudden departure from a well
established pattern of regular & predictable
menses is a complication of pregnancy—
threatened or spontaneous abortion & ectopic
pregnancy .

15. Birth 10 20
Estrogen Withdrawal
Anovulation
Coagulopathies
Infections
Complications of
pregnancy
Foreibdy
Trama ifctn ovarian tumr
sarcoma botroids
CAUSES :According to Age of
presentation to Doctors
ADOLESCENCE :10 to 19 years
Anovulation
Coagulopathies
Infections
Complications of
pregnancy
10

16. “ LACK OF CORRELATION BETWEEN
PERCEPTION & ACTUAL BLOOD LOSS
SO OBJECTIVE EVALUATION OF BLOOD
LOSS IS MUST
Several Studies

17. Objective Evaluation of HMB From
Menstrual History is Must
Qualitative Quantitative
Menses lasting more than 7
days
Changing pad or tampon
more than hourly
>80 ml blood loss
Clots greater than 1 inch in
diameter
Soaking through clothes
PBAC Score > 100

18. PBAC SCORE

19. ANOTHER TOOL TO ESTIMATE
BLOOD LOSS IS---HAEMOGLOBIN

20. CLINICAL CLASSIFICATION
DURATION FLOW
HAEMOGLOBIN
MILD > 7 OR < 24 FOR
2 MONTHS
MILD TO
MODERATE
10 -12
MODERATE > 7 DAYS MODERATE TO
HEAVY
< 10
SEVERE DISRUPTIVE HEAVY < 8

21. HISTORY—OF PATIENT IN
PUBERTY MENORRHAGA

22. History
• Detailed Menstrual Bleeding pattern-spend time with
patient.
• Amenorrhoea followed by prolonged HMB-as seen in
PCOS.
• Sexual history
• Medications( harmones ,I.PILL ,Antiseizure
.Antidepressants etc )
• Underlying systemic illness (Renal disease, Liver disease
,Thyroid etc )
• Personal /Family H/O bleeding disorder

23. Detail menstrual history-tells the
Diagnosis
• Age at menarche
• Onset of abnormal menses ( sudden ,gradual )
• Timing, duration, and quantity of her uterine bleeding
• Inter menstrual interval.
• Cramping and/or clots
-------------------------------------------------------------------
weight changes, eating pattern / exercises schedule
S trickland J, Gibson EJ, Levine SB. Dysfunctional uterine bleeding in adolescents.
J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.

24. Evaluation of H/O
BLEEDING DISORDERS
ONE OR MORE
 Epistaxis-> 10 min requiring medical attention
 Spontaneous bruising > 2 cm / minor wound bleeding > 5 min
 Bleeding from oral cavity/ GIT without obvious lesion
 Prolonged / excessive bleeding after surgery
 Hemorrhage requiring BT
• Family H/O bleeding disorders
 Significant bleeding complication not yet investigated

25. PCOS as a cause of PM
• PCOS can present as Puberty Menrrhagia.
• Possible risks of endometrial hyperplasia and
early development of endometrial carcinoma
in later Life require consideration &
counselling.

26. IRREGULAR PERIODS IN
IRREGULAR MENSTRUAL CYCLES ARE DEFINED AS:
2018 Guidlines

27. REGULAR MONTHLY HEAVY PERIODS 
TO ANATOMICAL LESION OR BLEEDING
DISORDER THAN TO ANOVULATION .
ANATOMICAL LESION

28. Physical exam-D/D guided
• Haemo dynamic status-pallor,tachycardia,BP
• acute / chronic HMB( > 6 months history )
• Degree of anaemia
• Features of bleeding disorder-
Ecchymosis,purpura
• Features of PCOS / BMI
• Features of Thyroid enlargement or other
Endocrinopathies
• P/S & P/V if sexually active

29. DETAILED EXAM & ULRASOUND +CBC + UPT
are logical first 4 steps.
It is cost effective & require little technical skill

30. GUIDELINES
Management
(Investigations+ Treatment)

31. INVESTIGATIONS
• UPT
• CBC
• USG
• Serum Progesterone on day 22 to 24 (<3 ng/ml.
• Bleeding disorder investigations
• TSH
• PCOS tests if needed
• Pelvic USG-to R/O PCOD, fibroids

32. Is USG needed in initial evaluation ??

33. Is USG needed in initial evaluation ??
In a Retrospective chart review of 230 patients <18 years old
presenting with PUBERTY MENORRHAGIA to the Gynecology clinic
• The most common diagnosis in both the ultrasound group and
non- ultrasound group with Puberty Menorrhagia was immature
HPO axis.
• Of the patients who received an ultrasound, 72% had normal
findings, incidental findings were identified in 18% and PCOS
morphology in 6%.
• Structural causes of AUB were found in only 2 (1.3%) of the
adolescents imaged.
• No patient had a change in her AUB management plan due to
ultrasound findings.
Pelvic ultrasound is not required in the initial investigation of
AUB in the adolescent population
J Pediatr Adolesc Gynecol. 2016 Oct 6. pii: S1083-3188(16)30206-6

34. ≥ 8 years after menarche
Ultrasound should
not
be used for the
diagnosis of PCOS
< 8 years after menarche
8MHz Probe,
The threshold for PCOM
should be on either ovary, a
follicle number per ovary of >
20 and/or an ovarian volume
≥ 10ml
New Guidelines 2018

35. We as group do feel ULTRASOUND
need to be done in evaluation of
Puberty Menorrhagia

36. PUBERTY MENORRHAGIA &
BLEEDING DISORDERS
See Detailed PPT in SLIDESHARE .NET
By DR SHARDA JAIN/ DR JYOTI AGARWAL on

37. Initial Laboratory Evaluation
for Bleeding Disorders
Initial
Evaluation
Complete Blood
Count
Prothrombin
Partial Thrombo
Plastin time
(aPTT)
Fibrinobin Time
(TT)
Von Willebrand
assay
Complete
Blood Count
Complete
Blood Count

38. EVALUATION of
Puberty Menorrhagia
BEFORE LABELLING AS ANOVULATION RULE OUT OTHER CAUSES
PCOS
THYROID
DISTURBANCES
PREGNANCY
STI
BLEEDING
DISORDERS
MEDICATIONS
SYSTEMIC
ILLNESS
TRAUMA
STRUCTURAL
CAUSES

39. EVALUATION – MAIN POINTS
INITIAL TRIAGE
HAEMODYNAMICALLY
STABILITY
PREGNANCY STATUS
UNSTABLE
HOSPITALISE
STABLE
NEGATIVEPOSITIVE
BETA HCG
TVS
Blood Group AND
CrossMatching
TESTS FOR BLEEDING
DISORDERS
MISCARRIAGE
ECTOPIC
MOLAR
OTHER CAUSES

40. Goals of Management
Determining factors for treatment-
• Clinical classification of Puberty Menorrhagia
• Underlying cause
• Control of Bleeding
• Prevent further episodes of Bleeding
• Treat Anaemia

41. Goals of Management
Determining factors for treatment- contd..
• Contraception need of patient if needed
• Prevention of long-term consequences of
anovulation
Anaemia,
Infertility
Endometrial hyperplasia
Endometrial cancer

42. CLINICAL CLASSIFICATION Of
PUBERTY MENORRHAGIA--must
DURATION FLOW HAEMOGLOBIN
MILD > 7 OR < 24
FOR 2 MONTHS
MILD TO
MODERATE
10 -12
MODERATE > 7 DAYS MODERATE
TO HEAVY
> 10
SEVERE DISRUPTIVE HEAVY < 10

43. Puberty Menorrhagia
Broad outline of TREATMENT

44. TREATMENT OF PUBERTY MENORRHAGIA IS
MEDICAL
IN ALMOST ALL CIRCUMSTANCES

45. Treatment Outline of
Puberty Menorrhagia Made Simple By
WHO criteria of Anemia
10 - 12
10 - 8
< 8
< 5 - 6
KEEP HEAMATOLOGIST IN LOOP IF HAS BLEEDING DISODERS

46. Multiple MEDICAL modalities
Used in Puberty Menorrhagia
• HAEMANITICS for ANAEMIA
• NSAIDS
• ANTIFIBRINOLYTICS
• HORMONAL
• REPLACEMENT OF MISSING COAGULATION
FACTOR

47. CORRECTION OF ANAEMIA
• For girls with mild or moderate AUB and mild
asymptomatic anemia ( Hb 10 - 12 g/dL), initiate
iron supplementation with 60 mg elemental iron
per day.
• For girls with severe AUB , initiate iron
supplementation as soon as the patient is stable
and able to take pills by mouth. Depending upon
the severity of iron deficiency, use 60 mg of
elemental iron once or twice per day. IV Iron
therapy in moderate to severe Anaemia.

48. BLOOD TRANSFUSION IF HB < 8 gm %

49. TREATMENT OPTIONS
HAEMOSTATIC

50. TRANEXAMIC ACID TREATMENT—is
drug of choice
• Tranexamic acid is administered orally:
1000 mg three times per day for up to
five days with each menses
Or
• 1 gm loading dose & 500 mg 3 times a
day
• Mefenamic acid 500mg 3 times a day

51. DESMOPRESSIN TREATMENT-is
favorite of few
• Desmopressin is administered IV as follows:
Desmopressin 0.3 mcg/kg IV over 15 to 30
minutes; the dose may be repeated in 48
hours if there is no response
Or
In Puberty Menorrhagia Dose is
900 mg daily, until the normalization of
menstrual cycle

52. DIOSMIN in Puberty Menorrhagia
Summary of Clinical Trials
• 100% Pure micronized diosmin is a potent , gentle, non-
hormonal treatment in cases of menorrhagia , with or
without hormonal therapy.
Summary of Clinical trials
I. Pure Diosmin reduces amount of bleeding upto 50%
II. Reduces duration of bleeding by 2.5 days
III. Relieves dysmenorrhea score by 50%
IV. Normalizes menstrual cycle by 80%.
V. Effective in Functional gynaecological bleeding in 88-98%
patients.
VI. Safe and well tolerated
: Int J Gynaecol Obstet. 2005 May;89(2):156-7,
Gobet A.: Med. Prat. 1978; (1-2): 713-14

53. AMINOCAPROIC ACID- TREATMENT-is
another choice
• AMINOCAPROIC ACID may be administered
orally or IV as follows:
Aminocaproic acid 4 to 5 g IV during the first hour
of treatment, followed by a continuous infusion at
a rate of 1 g per hour; treatment is continued for
approximately eight hours or until the bleeding
has been controlled.

54. HORMONE THERAPY
PUBERTY MENORRHAGIA
&

55. RATIONALE OF HORMONE THERAPY
I
Administration of exogenous estrogen permits
additional endometrial proliferation, which heals
the sites of endometrial bleeding, and provides
hemostasis
 Administration of progestin stabilizes the
endometrial lining

56. CONCERN of GYNAECOLOGISTS
• High doses of estrogen may cause premature
closure of the growth plates, reducing
ultimate adult height.
• However, by the time of menarche, most
female adolescents have already undergone
their growth spurt and achieved
approximately ≥95 percent of adult height.

57. PATIENT/ PARENTS EDUCATION
• In majority of patients , medical management cures the
problem
• Common side effects of high – dose oestrogens are : nausea ,
vomiting , headache , depression & fluid retention
contraindicated in liver disease, history of thromboembolic
disorder, cardiovascular disease & oestrogen – dependant
neoplasm
• Common side effects of Progestogens are depression , fluid
retention ,fatigue, insomnia , dizziness, nausea & breast
tenderness.
• Common side effects are acne , weight gain fluid retention ,
hoarseness of voice

58. PATIENT /PARENTS EDUCATION
• Emphasise on maintaining menstrual calendar
• Emphasise on correction of anaemia & good healthy
diet
• Explain about optimising Weight
• Evaluation , counselling & management of
breakthrough bleeding
• Explain risk of endometrial cancer in endometrial
hyperplasia in PCOD

59. MILD AUB
HAEMOGLOBIN CONTRACEPTION TREATMENT HORMONE
NORMAL
(12GM +)
NO OBERVATION AND
REASSURANCE
NO
10-12 GM% YES / NO IRON THERAPY YES
KEEP A MENSTRUAL CALENDAR
FOLLOW UP IN 2 - 3 MONTHS – UNLESS SEVERE BLEED
RPT CBC

60. Mild Puberty Menorrhagia-
Hemodynamically stable
• Hb > 10 gm %
• Decide about COCP / Progestogen
• May need to increase dose of COCP to BD and then
taper
• Follow up with iron supplementation + COCP if
started.

61. SAMPLE PRESCRIPTION
PM with HB 12 GM or MORE
• Tab Tranexamic acid 1 gm loading dose
followed by 500 mg 3 times a day.OR
• Tab Mefenamic acid 500 mg 3 times a day.
• Good Diet
• Iron+ folic acid 60 mg once a week.

62. SAMPLE PRESCRIPTION
HB <12 gm but > 10 gm
• Tab Tranexamic acid 1 gm loading dose followed by 500
mg 3 times a day. Treatment of choice OR
• Tab Mefenamic acid 500 mg 3 times a day.
+
• Cyclic oral contraceptive pill ( OCP )
OR
• If OCP contraindicated ,Medroxy-progesterone acetate
(MPA ) 10 mg from 16 -26 day OR
• Norethisterone 5 to 10 mg BD from 16 to 26 day
• +Iron tab daily

63. HARMONE—TO GIVE PROGESTOGEN OR COCP ?
• Although cyclic progestin Therapy generally works
well in girls who are completely Anovulatory & not
sexuall active,
• Treatment with an oestrogen-progestin contraceptive
is better choice for those who are likely still ovulate (
infrequent ) or want to avoid pregnancy.
• Experts feel standard cyclic PROGESTIN Therapy does
not reliably suppress the HPO axis.,so they will not
prevent random ovulation & are NOT contraceptive.

64. Combined hormonal contraceptive
(OCP ) in INDIA—is choice
• COCP-cyclic IS MOST PRESCIBED-with
Anovulatory bleeding, & who may be
sexually active.
• Acute prolonged episodes of HMB also can
be effectively managed with High dose
COCP provided the endometrium is normal
or increased thickness .

65. COCP – to be given for 3 to 6 months
Monophasic OCP containing 30 µg - 35 µg ethinyl
estradiol (preferred for most adolescent )
Progestogen in OCP can be any of the following :
• Norgestrel 0.3 mg/ ethiny estradiol 30 µg
• Levonorgestrel 0.15 mg / ethiny estradiol 30 µg
• Norgestimate 0.25 mg/ ethiny estradiol 35 µg
Regular daily use with monthy withdrawal bleeds
or extended cycle (elimination placebo pills)

66. PROGESTOGEN ONLY THERAPY
It is indicated for adolescent in whom oestrogen is
contraindicated or poorly tolerated.
• Medroxyprogesterone 10 mg po daily continously or
for 10-12 d/month
• Norethindrone acetate 5-10 mg po OD or BD daily
Treat for at least 6 months
then reassess for need for therapy if desired

67. COUNSELLING with M P A
• Instruct patients to take oral MPA 10 mg every night for the first
12 days of each calendar month as this regimen seems the easiest
for teenagers to follow.
• It is not a method of contraception.
• Oral micronised progesterone are not effective.
• If they become sexually active and desire contraception they will
need COC.
• If they have unprotected sexual intercourse while using progestin-
only therapy, emergency contraception may be warranted.

68. Various Hormonal Therapy as
practiced by Gynaecologists in INDIA
• COCP-cyclic IS MOST PRESCIBED
• OCP continuous- adolescents In western
world prefer extended cycles (84/ 7)
• Transdermal patch (not given in INDIA )
• Vaginal ring (not given by Gynaecologists )

69. MODERATE BLEEDING
HAEMOGLOBIN 8 TO 10 GM %

70. Treatment of Puberty menorrhagia
10 - 12
10 - 8
< 8
< 5 - 6
KEEP HEAMATOLOGIST IN LOOP IF HAS BLEEDING DISODERS

71. Moderate HB <10GM %
• Mostly outpatient Treatment
• The treatment typically involves Hormonal Therapy to stabilize
endometrial proliferation and shedding.
• The choice of agent(s) depends, to some extent, upon how
heavily& actively the patient is bleeding.
• Girls with moderate PM should be provided with iron
supplementation +IRON /Protein rich diet
• COC pills be taken 2 to 3 times per day until the bleeding ceases
(usually within 48 hours), then tapered to twice daily for 5 days,
and then decreased to once daily to complete 21 days of hormone
therapy.
R imsza ME. Dysfunctional uterine bleeding. Pediatr Rev. 2002;23(7):227-233.

72. COC
• Oral contraceptive pills taper protocol
using monophasic pills can also be given,
• 4 pills evenly spaced per day for 4 days,
• 3 pills per day for 3 days,
• 2 pills per day for 2 days and
• 1 pill /per day for 2 months without taking the
placebo pill.
Linda M, Szymanski, Kimberly B Abnormal uterine bleeding,
The John Hopkins manual of Gynecology and obstetrics Third
edition page 417-428 Lippincote Williams and wilkins

73. • Heavy bleeding can also be treated with oral
PROGESTERONE Medroxyprogesterone 10 mg three times
/day for 14 days.
• Medroxyprogesterone acetate injection (Depo Provera) 150
mg intramuscularly every 12 weeks.
• Progesterone can also be used for medical curettage, in the
form of Norethisterone Acetate 20-30 mg daily for 3 days to
arrest haemorrhage.
• It may then be continued at a lower dose for up to 21 days.
Withdrawal bleeding will occur on stopping the treatment
that ceases in 4-5 days
MPA - as alternative TREATMENT

74. Norethisterone acetate (NETA)
– another favourite
• Different dosing regimens are in practice
• NETA 5-10 mg, generally administered in luteal phase from day 15/19 to
day 26 in anovulatory cycles
• Recently an increase in the duration and dosage has been investigated in
patients with ovulatory dysfunctional uterine bleeding
• Administration of oral progestogens from day 5 to day 26 of the cycle
produced a significant reduction in bleeding
• Acute anovulatory bleeding:
• High dose NETA 15 mg & treatment should continued for 3 weeks,
tapering the dose after 7-10 days Lethaby et al.
In studies, Norethisterone progestogens were more effective in the
treatment of Abnormal uterine bleeding than dydrogesterone.
(Am. Med. J. 1 (1): 23-26, 2010)

75. Norethisterone acetate controls bleeding and
normalizes menstrual cycle by the following actions:
• Effects on Uterus:
• Binds to progesterone receptors in the endometrium and brings
synchronous secretory changes in oestrogen primed endometrium
• Promotes regrowth of the endometrium over irregularly denuded
surfaces due to its weak estrogenic action
• Styptic effect on uterine hemorrhage:
• Checks bleeding by constriction of uterine blood vessels (like a
hemostatic agent).
•
• Used for the management of acute bleeding as well as for the
prevention of recurrence. Beneficial in both ovulatory and
anovulatory DUB.

76. Side effects of PROGESTERONE only therapy
• Break Through Bleeding
• Need for long-term oral medication and the possibility of unwanted
`pre- menstrual symptoms’
• Androgenic effects (depending on the progestogen used), such as
acne and hirsutism; irregular breakthrough bleeding and a change in
carbohydrate tolerance and lipid balance.
• Depo-Provera will induce amenorrhoea in 50% of users at 1 year and
break through bleeding in 15±20%---not used in Puberty Menorrhagia
very often..
.

77. • Use Monophasic COCP with a minimum of 30
mcg EE to ensure a sufficient amount of
Oestrogen to prevent breakthrough bleeding
• One pill every eight hours until the bleeding stops
(usually takes 48 hours )
• One pill every 12 hours for 5 days, then
• One pill once per day for a total of at least 21 days
• Close follow-up (in person or by phone) is essential while the pills
are being taken two or three times per day.
HOW TO PREVENT B.T.B.

78. SEVERE BLEEDING

79. RULE OF Treatment
ACTIVE BLEEDING
• Combined oestrogen-progestin oral
contraceptives rather than progestin-only
hormone therapy
BECAUSE ESTROGEN PROVIDES HAEMOSTASIS

80. HORMONE THERAPY
(commonly used in Heavy Bleeding)
Use OCP with doses of oestrogen (eg, 30 or 35 mcg ethinyl
estradiol)
●One pill every six hours until the bleeding subsides (usually within
24 hours)
●One pill every eight hours for three days, then
●One pill every 12 hours for up to two weeks
Antiemetic therapy --PromethazinPe 12.5 to 25 mg orally or
ondansetron 4 to 8 mg orally) may be required for girls who are
taking more than one pill per day.

81. PARENTERAL ESTROGEN
Reserved for patients with
 Severe anovulatory uterine bleeding who are
unstable and cannot take oral medications
 If bleeding is not controlled after 24 hours of
combination hormonal therapy.

82. Treatment of SEVERE BLEEDING
Hemodynamically unstable Patient
-needs HOSPITALISATION
• Hb < 8 gm %
• Fluid and blood Transfusion
• Inj Conjugated equine oestrogen
• Inj Tranexamic acid 1gm loding dose followed
by500mg IV 8 hourly for 5 days
• Simultaneous with IV Conjugated oestrogen---
start COCP containing 30-35 Ug EE orally every 4-
6 hrs till bleeding stops and taper to or BD over
10-14 days

83. PRACTICAL TIPS with I/V CE
• The dose of IV CONJUGATED ESTROGEN is 25 mg
every four to six hours until the bleeding stops.
• No more than six doses should be administered
• Thromboembolism is a potential complication
• Administration of antiemetics one hour before
each dose of IV estrogen may alleviate the side
effects of nausea and vomiting

86. Role of SURGERY
Role of surgery – endometrial curettage
• Acute bleeding in Heamodynamically unstable
patient to quickly control the bleeding.
• In acute episode , if bleeding does not decrees
significantly in 12-24 hours with medical treatment ,
than re-evaluation is mandatory & surgical
curettage should be done

87. Rarely Used

88. HOSPITALISATION – INDICATIONS
• Hemodynamic instability
• Hemoglobin concentration <8 g/dL
• or <10 g/dL with active heavy bleeding
• Home management with daily monitoring may be possible for
patients with hemoglobin between 8 and 10 g/dL if the patient is
hemodynamically stable and the patient and family are reliable
and can maintain close telephone contact.
• Symptomatic anaemia (eg, fatigue, lethargy)
• Need for intravenous conjugated estrogen (eg, cannot take oral
medications, continued heavy bleeding after 24 hours of
oestrogen-progestin combination therapy) or surgical intervention
• Need for surgical intervention

89. PRACTICAL TIPS of FOLLOW-UP AND
LONG-TERM CARE
• After treatment is initiated, patients should be seen
at regular intervals whatever is grading of puberty
menorrhagia.
• Long-term management depends on the anaemia
and the desire for contraception.
• Most experts recommend continuing hormonal
therapy for at least 6 months.
• After therapy is discontinued, the patient should
still be followed to ensure regulation of
menstruation.

90. Dr Sharda Jain
MD, (PGIMER), MAMS , FICOG, FIMSA, DHM, QM & AHO PGDMLS (SYMBIOSIS)
Regd. No 11076/ DMC No 2734
ACADEMICIAN & SURGEON PAR EXELLENCE
Taught for 2 decades at PGIMER (Chandigarh )+LHMC(Delhi
DIRECTOR : Lifecare Centre + Lifecare ABS
Lifecare IVF * GLOBAL STEMGEN
MEMBER : Ethical Committee of India (MCI)
EXPERT : Delhi Medical council for last 12 years
FOUNDER & SECRETARY GENERAL : Delhi Gynaecologis Forum
FOUNDER & CHAIRPERSON : WOW India
CHAIRPERSON : Medico Legal Foundation
FORMER NATIONAL CHAIRPERSON : Women Wing , IMA (2004-2007)
ADVISOR HEALTH : National Commission For Women (2001-2004)
MEMBER : Central / State Sup, Board PNDT Act
Ex PRESIDENT: LHMC Alumini Association (2010-2011)
CHAIRPERSON : Dept. Obg/ Gynae Pushpanjali Crosslay Hospital (Max Vaishali) (10 yrs)
Ex PRESIDENT : A.M.C. Delhi NCR
Over 1000 TALKS / Nearly 370 PPT in Slideshare.in/ chapters in books/> 150 Publications
Awards :Lifetime Achievement Awards: FOGSI ,DGF.LHMC Alumini,WOW India
+many more

91. Name : Dr Jyoti Agarwal
Qualification : MBBS (Gold Medalist through out,DU)
M.D (Gynae & OBST –LHMC ,DU )
FICOG
Designation : Senior consultant & Director
Lifecare Centre & Lifecare IVF
11 Gagan Vihar Delhi – 51
Area of Interest : IVF, Infertility , Ultrasound ,Teaching, Zumba
Over 350 PPT ON SLIDESHARE.in Gynae/IVF/USD
Academic Activities : *PRESIDENT of D.G.F.(East)
*AOGD COMMITTEE Member-Adolescent/Safe Motherhood
*Certified trainer of DGF for infertility ,IVF & ultrasound
*Participated in various National CME &
workshop as a faculty
*Treasurer D.G.F. Since Inception
Awards :
Dr. Jyoti Agarwal
Received 2 dozen awards during MBBS &
MS , including President Gold Medal
• APJ appreciation awards from Delhi
Gynaecologist forum
• Teacher’s Excellence Award in 2016
from Delhi Gynaecologist forum

92. USP of Delhi Gynaecologist forum
Training of Doctors in
- Diploma course in IVF- ICSI- Embryology
-Certficate course in A to Z of Male /Female Infertility
-
- Basic Ultrasound course
- Colposcopy
- PGDMLS (Diploma course in Medico Legal Issues)
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