Heavy menstrual bleeding (HMB) is common among adolescents, with one US study estimating a prevalence of 27% in female patients ages 10-17. It is also commonly distressing, such that the American College of Obstetrics and Gynecology (ACOG) defines HMB not only by its quantity (>80 mL of total blood loss or > 7 days of bleeding) but also by its interference with “a woman’s physical, social, emotional, or material quality of life.” For an adolescent girl, HMB can have a tremendous impact on her school attendance, participation in extracurricular activities, confidence, and mood. It may also be the first indicator of an underlying hematologic or endocrinologic condition. So when she comes to Emergency Department, how can we not only address her current bleeding but also assess- thoroughly yet thoughtfully- for any underlying causes? Let’s dive in. 

Why Adolescents May Bleed Heavily

The classic mnemonic for abnormal uterine bleeding is PALM COEIN: Polyps, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified. In adolescent patients, two of these causes account for the vast majority of heavy menstrual bleeding: anovulation, followed by bleeding disorders, and these will be the focus of our initial workup. 

Anovulation in adolescents is usually due to an immature hypothalamus-pituitary-ovarian axis. With anovulatory cycles, the endometrium may get thicker than normal and cause heavier bleeding when a period does occur. However, the majority of these patients still have periods every 21-45 days which last <7 days and don’t meet the definition for pathologic heavy menstrual bleeding. Other, less common causes of anovulation include hypothyroidism, pituitary adenomas, and polycystic ovarian syndrome (PCOS). 

Bleeding disorders affect 1-2% of the general population. However, 20% of adolescent girls presenting with HMB and 33% of adolescent girls hospitalized for HMB have an underlying bleeding disorder. Moreover, 75-80% of girls and women with a diagnosed bleeding disorder report heavy menses- it’s the most common clinical manifestation! In an adolescent, HMB might actually be the first sign of a bleeding disorder if she hasn’t had previous challenges to her coagulation system, such as a surgery or tooth extraction. The most common underlying diagnoses are von Willebrand Disease, platelet function defects, thrombocytopenia, or clotting factor deficiencies. 

So, while many adolescents with heavy periods simply have an immature HPO axis, how do you make sure that you’re not missing something underlying? Fortunately, there are some simple screening tools and basic labs that can guide your workup and make you a star when you call for a Gynecology or Hematology Consult.  

But First, an Aside…

When an adolescent girl comes to the Emergency Room for heavy menstrual bleeding, she is likely feeling embarrassed, overwhelmed, and isolated. She almost certainly doesn’t want to talk to a stranger about her periods. Establishing a trusting rapport is essential before moving forward with your H+P. Remind her that many adolescents have heavy periods, you have ways of controlling her bleeding, and she doesn’t have to live with heavy periods forever. Offer her the opportunity to answer questions without her parent/guardian present. Make sure that she has the pads and/or tampons that she needs. 

History

First, you need to ascertain whether your patient has true, pathologic heavy menstrual bleeding. Most women, let alone adolescents, would be hard-pressed to estimate the volume of blood loss during an entire menstrual cycle, though the helpful diagram below from fellow PEM blog Don’t Forget the Bubbles may help. Remember, >80 mL total is indicative of HMB. 

Courtesy Don’t Forget the Bubbles and Tara George – https://dontforgetthebubbles.com/period-problems-menorrhagia/

In lieu of volume measurements, an international panel of gynecologists recommended the following two history questions: 

  1. Have you soaked through a pad or tampon in <1-2 hours? 
  2. Have you soaked through bedding? 

A history of clots >1 inch in diameter may also be predictive. If a patient has already had lab workup, anemia and/or low ferritin can also make the diagnosis of abnormal HBM. 

Once a diagnosis of HMB has been made, it’s time to assess for underlying causes. If any one of the following four criteria are met, both ACOG and ASH recommend assessing for a bleeding disorder: 

  1. Do your periods last 7 or more days AND do you have flooding (changing pad/tampon hourly) or impairment of daily activities with most periods?
  2. Do you have a history of anemia treatment?
  3. Has anyone in the family been diagnosed with bleeding disorder?
  4. Do you have a history of excessive bleeding with tooth extraction, delivery, miscarriage, or surgery? 

While they are less common, remember to also keep endocrinologic disorders on your differential. It’s important to ask about symptoms of hypothyroidism and PCOS. Some of these questions might require input from a parent. 

Physical Exam

Begin with an assessment of hemodynamics, including orthostatics. Look for pallor, bruising, and/or petechiae that may indicate anemia. Check for abdominal distention, hepatosplenomegaly, and masses. And, critically, don’t forget Tanner Staging! In order to have menstrual bleeding, a patient should be at least Tanner Stage III. If she’s not, you should have a high suspicion for trauma. Also perform an external genital exam, though per ACOG, you do NOT typically need to do a speculum exam. 

Lab Workup

Labs should focus on assessing for anemia, coagulopathies, and endocrinologic disorders. ACOG recommends the following for all adolescents presenting with HMB: CBC, ferritin, urine hCG, TSH, PT, aPTT, fibrinogen, vWF activity + antigen, Factor VIII. If sexually active, add gonorrhea and chlamydia. If the patient has signs of excess androgens, add DHEA, total and free testosterone, and prolactin. If your patient is hemodynamically unstable, add a type and screen. 

Imaging

Imaging is typically not recommended in your first-line workup. If a patient fails empiric management (more on that soon), her outpatient providers may arrange an ultrasound. 

Management

Talking to Gynecology and potentially Hematology (based on labs) will be important both for disposition and for follow-up. While many patients can be discharged home with close outpatient follow-up, 5% of those admitted will actually require ICU-level care. 

You should admit your patient if she has any one of the following characteristics: 

  • Active profuse heavy bleeding
  • Bleeding through >1 pad/hour for more than 2 hours
  • Hypovolemia
  • Orthostatic hypotension
  • Hgb <8 or Hct <25

However, if you’re able to discharge your patient, you need to set her up for success in three ways: addressing her bleeding, repleting her iron stores, and ensuring good follow-up. Unless she has contraindications to estrogen (see below), start a combined oral contraceptive pill with 30-50 mcg ethinyl estradiol every 6-8 hours until bleeding stops and then taper (Gynecology should help guide this). High-dose estrogen can cause nausea, so antiemetics will be essential for adherence. Start all patients on oral iron and consider a stool softener to combat resultant constipation. Patients should be counseled to return to the ED if they have no improvement in 24 hours. Otherwise, they should have gynecology follow-up within 7 days. 

If a patient has a contraindication to estrogen (migraine with aura, hypertension, prior clot or high risk for clot, transplant, congenital heart disease), substitute medroxyprogesterone 10 mg q4-6h or norethindrome 20mg q8h to control bleeding, which Gyn should then help taper. The rest of your management and counseling is the same. 

Take-Home Points

  • An immature HPO axis is the most common cause of heavy menstrual bleeding in adolescents: HOWEVER, you should have a high suspicion for a bleeding disorder. Endocrine disorders are less common but should also be on your differential. 
  • There are 4 easy questions to ask to assess for a bleeding disorder in an adolescent with heavy menstrual bleeding 
  • Physical exam should include an assessment of hemodynamics and Tanner Staging: patient should be at least Tanner III to be menstruating
  • Labs will screen for the most common causes of HMB as well as iron deficiency
  • All patients should be started on hormones (to stop bleeding) and iron (to replete stores) with close outpatient follow-up 

References

Adeyemi-Fowode, O., & Simms-Cendan, J. (2019). Screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Obstetrics and gynecology, 134(3), E71-E83.

James, A. H. (2016). Heavy menstrual bleeding: work-up and management. Hematology 2014, the American Society of Hematology Education Program Book, 2016(1), 236-242.

O’Brien, S. H. (2018). Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist. Hematology 2014, the American Society of Hematology Education Program Book, 2018(1), 390-398.

Tara George. Period Problems: Menorrhagia, Don’t Forget the Bubbles, 2021. Available at: https://doi.org/10.31440/DFTB.32371