A 15 yr old standard ten drop out hailing from a low socioeconomic status presented with generalized lymphadenopathy and parotid gland enlargement since 2 months. She had polymenorrhagia since 6 months. Her haematological investigations revealed a markedly elevated total leucocyte count with low platelet levels. Bone marrow biopsy showed 25%myeloperoxidase negative blast cells, suggestive of Acute Lymphoblastic leukaemia. She was treated with haematinics, antifibrinolytic agents and progesterone. She responded to the above line of management. She is currently undergoing chemotherapy for ALL.

Introduction
Abnormal uterine bleeding can pose a significant challenge to every gynaecologist particularly when associated with serious complications. The most common cause of abnormal uterine bleeding is anovulatory cycles due to immaturity of the hypothalamic pituitary ovarian axis. 80% of gynaecological visits are due to abnormal uterine bleeding.1 50% of these cases are due to anovulatory cycles.2 20% of adolescents with menorrhagia have blood dyscrasias.

Case Report
A 15 year old female standard tenth drop out hailing from a low socioeconomic status presented to the haematology ward with chief complaints of generalised lymphadenopathy and bilateral parotid gland enlargement since 2 months and polymenorrhagia since six months. She had attained menarche at 14 years. Her present menstrual cycles occurred every 20 to 22 days, lasted for 8 to 10 days, were heavy, painless, regular. On clinical examination her general condition was below average. She had severe pallor. Her vitals were within normal limits. Per abdominal examination did not reveal any significant pathology. The cervical and inguinal lymph nodes were enlarged firm and nontender. Her bilateral parotid glands were enlarged and tender.

Baseline haematological investigations revealed haemoglobin of 6 g%, total leucocyte count of 5,58,000/cmm and platelet count of 7000/cmm.

Liver and renal function tests were within normal limits. Her thyroid functions were normal. Tuberculosis was ruled out in this patient as sputum examination and chest X-ray were within normal limits.

In view of her high leucocyte count the haematologist performed a bone marrow biopsy. This revealed myeloperoxidase negative blast cells suggestive of acute lymphoblastic leukaemia.

The patient was transfused with 2 units of fresh whole blood in view of severe anaemia. Post transfusion she was administered C. Ferrous sulphate 200 mg BD, to build up her haemoglobin. To combat her menorrhagia she was started on antifibrinolytic Tranexemic acid 500 mg TDS and T. Norethisterone acetate 10 mg TDS. The patient responded to the above primary line of treatment.

Figs. 1 and 2 : Bone marrow cytology pictures depicting acute lymphoblastic leukaemia

Discussion
The present case highlights the importance of acute lymphoblastic leukaemia as the underlying aetiology in a case of puberty menorrhagia. 19% adolescents with menorrhagia requiring hospitalisation have coagulation disorders of which leukaemias form an important cause.3 With induction of chemotherapy more than 80% cure rates have been achieved.4 The drugs used primarily are Vincristine and prednisolone. The second line drugs include Daunorubicin and L-Asparaginase. Treatment is generally divided into phases: induction, intensification and maintenance. The goal of induction is remission, eradication of all microscopically detectable leukaemia. The goal of maintenance is preservation of remission. Childhood ALL is in particular is unique in its requirement for prolonged 2 to 3 year moderate therapy. Aggressive post induction intensification has been the focus of recent efforts in ALL and has resulted in striking improvements in outcome.

These drugs in the induction phase are administered cyclically for 1 month. This is followed by reevaluation of the haematological counts. Absence of circulating blast cells, total count less than 11000 cells/cmm, and a platelet count of more than 1 lakh cells/cmm are suggestive of complete remission. In childhood ALL 3 drug induction has proved superior to Vincristine and prednisolone in terms of long term event free survival.5 The maintenance phase is then initiated with 6 mercaptopurine or methotrexate for 4 to 8 weeks. Daily 6 mercaptopurine and weekly methotrexate with extended periodic intra thecal treatment are the most common maintenance or continuation therapy. However no advantage has been shown for high intensity 6 mercaptopurine or methotrexate.6 In addition to chemotherapy supportive treatment with component therapy is also required.

Conclusion

Acute Lymphoblastic leukaemia is the most common malignant disease in children and young adults causing 30% of all childhood cancers.7 In every case of puberty menorrhagia appropriate history, meticulous clinical examination followed by baseline haematological investigations is required. Pregnancy should always be ruled out. The gynaecologist should keep in mind rarer causes like leukaemia which may present with menorrhagia at the onset of puberty. The strikingly improved disease free survival of children with ALL and the availability of a variety of useful therapeutic strategies compel a careful consideration of the long term sequelae of treatment.

References

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