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GCO 290504

REVIEW

CURRENT
OPINION Evaluation and management of heavy menstrual
bleeding in adolescents
Lisa M. Moon, Gisselle Perez-Milicua, and Jennifer E. Dietrich

Purpose of review
Heavy menstrual bleeding (HMB) is a common condition in women of reproductive age; however,
adolescents with this issue present unique challenges in both diagnosis and management. Much of
the research into this topic focuses on the adult population, with variable applicability to
adolescents. There are currently no standard guidelines for the work up and treatment of adolescents
with HMB.
Recent findings
Current research into this topic has explored the utilization of standardized protocols in the evaluation of
HMB in adolescents, the efficacy of various hormonal, nonhormonal, and surgical treatment modalities,
and the benefits of a multidisciplinary approach. Recent literature has focused on adolescents found to
have an underlying bleeding disorder, recommending more comprehensive bleeding disorder work up to
identify these patients in a timely manner and initiate effective treatment plans.
Summary
Providers in the primary care setting should be aware of the definitions for normal menses, and be able to
recognize abnormal bleeding and HMB. Early recognition of HMB in adolescents can then lead to
appropriate diagnosis of underlying disorders, and current research has proposed standard protocols to
assist with the evaluation, ultimately leading to effective long-term management into adulthood.
Video abstract
http://links.lww.com/COOG/A40
Keywords
abnormal uterine bleeding, adolescents, bleeding disorder, heavy menstrual bleeding

INTRODUCTION 90% of cycles still fall within this range. Further


The prevalence of heavy menstrual bleeding (HMB) evaluation is warranted when cycles fall outside this
&&

is 10–20% in adult women, but higher in adoles- range [5 ]. Bleeding should last at least 7 days, and
&& &
&
cents (37%) [1 ]. HMB is a condition with signifi- pad/tampon use should average 3–6/day [5 ,6 ].
cant impacts on adolescent quality of life due to HMB is defined as bleeding more than 7 days or
&

school absenteeism and limitations to sports or more than 80 ml of blood loss/menstrual cycle [6 ].
&
social activity participation [2 ,3,4]. In one survey, Some additional signs of HMB include changing a
almost 60% of adolescents reported that HMB had pad or tampon less than 1–2 h, use of double hy-
&
a serious effect on life activities [2 ]. It is vital giene protection, frequent soiling of clothes or bed
that providers accurately recognize, evaluate, and sheets, blood clots more than 1 inch diameter, or
&

treat abnormal uterine bleeding (AUB) and HMB affects quality of life [6 ].
in adolescents.

NORMAL MENSES Baylor College of Medicine, Houston, Texas, USA


The average age of menarche is 12–13 years, with Correspondence to Jennifer E. Dietrich, MD, MSc, Baylor College of
the first menstrual period typically occurring 2–3 Medicine, 6651 Main St, Suite 1020, Houston, TX 77030, USA.
&&
years after thelarche [5 ]. Menses should occur Tel: +1 832 826 7464; e-mail: jedietri@bcm.edu
every 21–45 days, and although there is some irreg- Curr Opin Obstet Gynecol 2017, 29:000–000
ularity in the first several years after menarche, DOI:10.1097/GCO.0000000000000394

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Adolescent and pediatric gynecology

&
challenges until menarche [8 ]. For these reasons,
KEY POINTS it is recommended that providers give anticipatory
 Anticipatory guidance regarding puberty and normal guidance to patients and families prepubertally
&&

menstrual patterns should be given to patients and their [5 ]. Providers should treat menses as a vital sign,
families starting around age 7–8, and providers should documenting last menstrual period and menstrual
ask for the last menstrual period and document patterns each visit in an effort to identify abnormal
menstrual patterns at every visit after menarche. &&
menses earlier [5 ]. Physicians should ask patients
 The most common causes of HMB in adolescents are to track cycles, using a chart or electronic applica-
&& &

nonstructural, and include anovulatory bleeding from tion for improved recall [5 ,9 ].
immature HPO axis or PCOS and bleeding disorders
such as vWD and platelet function disorders.
DIFFERENTIAL DIAGNOSIS
 Utilizing a standard protocol for evaluation of
adolescents presenting with HMB can improve time to Once it has been determined that an adolescent has
diagnosis and management. HMB, it is crucial to complete a thorough work up
for underlying causes. Providers should refer to
 Multidisciplinary clinics can provide complete
evaluation and collaborative management plans for
the International Federation of Gynecology and
adolescents with bleeding disorders. Obstetrics classification system for AUB/HMB
(Table 1) [10]. As opposed to adult women, the most
 Many hormonal and nonhormonal therapy options are common causes of HMB in adolescents are non-
available for the management of HMB; surgical structural, with anovulatory bleeding and bleeding
management in the adolescent population is reserved &

for life threatening situations or as a last resort when


disorders being most common [1 ]. Anovulation in
medical management fails. adolescents may be because of the immature HPO
axis from recent menarche; however, this is a diag-
nosis of exclusion. Polycystic ovary syndrome
(PCOS) is another common cause of anovulatory
CHALLENGES TO DIAGNOSIS IN THE bleeding, and is frequently underrecognized in ado-
ADOLESCENT POPULATION lescents; the percentage of PCOS causing severe
HMB in adolescents is a challenging but often over-
&
AUB has also increased in recent years [11 ]. Bleed-
looked problem, and there is frequently a delay in ing disorders are rare in the general population [von
diagnosis. It is often difficult to obtain an accurate
&
Willebrand disease (vWD) prevalence is 1% [1 ]],
menstrual history from adolescents because of many however in patients with HMB the incidence of
factors: inconsistency with disclosure, recall difficul- bleeding disorders is disproportionately increased,
ty, variety in feminine hygiene product use, and with up to 30% of adolescents found to have a
cycle-to-cycle variability, so information obtained
&
bleeding disorder (Table 2) [12 ,13]. Other causes
regarding one period is not generalizable [7]. of HMB include thyroid disease, pregnancy, sexual-
Additionally, children may have an undiagnosed ly transmitted infections, and medications (Table 3)
bleeding disorder because of lack of hemostatic
& & &
[6 ,11 ,14 ].

Table 1. International Federation of Gynecology and Obstetrics classification system for causes of abnormal uterine bleeding
in nongravid women of reproductive age, using the acronym PALM-COEIN
PALM: Polyp AUB
Structural causes
Adenomyosis AUB
Leiomyoma AUB-L Submucosal (AUB-LSM)
Other (AUB-LO)
Malignancy and hyperplasia AUB
COEIN: Coagulopathy AUB
Nonstructural causes
Ovulatory dysfunction AUB
Endometrial AUB
Iatrogenic AUB
Not yet classified AUB

AUB, abnormal uterine bleeding.


Adapted with permission [10].

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Heavy menstrual bleeding in adolescents Moon et al.

Table 2. Red flags of bleeding disorders Table 3. Differential diagnosis of heavy menstrual
bleeding in adolescents
Red flags of bleeding disorders
Endocrine
Prolonged bleeding from trivial wounds lasting >15 min Anovulatory bleeding
Heavy, prolonged, or recurrent bleeding after surgery Polycystic ovary syndrome
Heavy, prolonged, or recurrent bleeding after dental procedures or Thyroid disease
tooth extraction
Bleeding disorders
Bruising with minimal or no trauma, especially resulting in a lump
von Willebrand disease
1–2 times/month
Platelet dysfunction
Nose bleeds lasting >10 min or requiring medical attention 1–2
times/month Thrombocytopenia
Unexplained bleeding from the gastrointestinal tract Clotting factor deficiency
Anemia requiring iron therapy or transfusions Infection
Heavy menstrual bleeding Sexually transmitted infections
Family history of bleeding disorders such as von Willebrand disease Cervicitis
or hemophilia Endometritis
Family history of hysterectomy at a young age Pregnancy
Postpartum hemorrhage Abortion
&
Ectopic pregnancy
Adapted with permission [6 ].
First trimester bleeding
Gestational trophoblastic disease
Postpartum bleeding
EVALUATION Medication
HMB may be either acute or chronic, therefore Anticoagulants
patients may present in the clinic or emergency Depot medroxyprogesterone
setting. A focused history and physical exam will Intrauterine Device
help to guide the differential diagnosis and work up
&& Uterine
(Tables 4 and 5) [15 ]. It can be useful to have
Leiomyoma
patients fill out screening surveys or bleeding
Polyp
charts to aid the history; however, these have most-
ly been studied in the adult population. In one Aenomyosis
study, the Pictorial Blood Assessment Chart was Malignancy
shown to be effective in adolescents as well, using Other
the same cutoff score (>100) to determine HMB Trauma
that warrants further work up [7]. Another fre- Foreign body
quently used screening tool is the International Hemorrhagic ovarian cysts
Society on Thrombosis and Hemostasis Bleeding
& &
Assessment Tool [8 ].
&
Adapted with permission [6 ,11 ].

One particular challenge in the evaluation and


management of adolescent HMB is that there may
be incomplete or inconsistent evaluation, and wide All adolescents presenting with HMB should
variations in management. One recent study found have an initial evaluation that includes screening
that among adolescents who had presented emer- for bleeding disorders, anemia, iron deficiency, thy-
gently with AUB, only 52% of patients had age of roid abnormalities, and pregnancy (Table 6) [18 ].
&&

menarche recorded, and only 45% of providers First tier bleeding disorder work up includes a von
asked about symptoms that would suggest a bleed- Willebrand panel, coagulation tests, and platelet
&
ing disorder [16 ]. In the same study, only 23% of aggregation studies; recent studies have shown that
patients had laboratory evaluation for a bleeding platelet function disorders are the second most
&
disorder [16 ]. It has been demonstrated that a mul- common bleeding disorder in adolescents, and
tidisciplinary clinic utilizing a standard protocol for screening for these should also be included
work up of adolescents with HMB improves time to & &&
[1 ,18 ,19]. It is important to note several factors
diagnosis. In one study, a historical cohort of wom- can affect bleeding disorder testing. Acute bleeding
en with type 1 vWD had an average time to diagno- episodes, stress, and high doses of estrogen (>50 mg)
sis of 16 years, whereas the study’s multidisciplinary can affect von Willebrand factor; recent NSAID use
&&
clinic average was only 4 months [17 ]. and selective serotonin reuptake inhibitors can

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Table 4. Focused history for evaluation of heavy menstrual Table 5. Focused physical examination for evaluation of
bleeding in adolescents heavy menstrual bleeding in adolescents
Menstrual history and bleeding pattern Vital signs
Age of menarche, regularity of menstrual cycle, quantity of Temperature, blood pressure, pulse, orthostatics (as clinically
bleeding, frequency of changing pads or tampons, presence of indicated), height, weight, BMI
clots, soiling of clothes or bed sheets, impact on quality of life Neck
Symptoms of anemia Thyroid examination
Headache, palpitations, shortness of breath, dizziness, fatigue, Abdomen
pica
Tenderness, distension, striae, palpable masses, hepatomegaly
Sexual and reproductive history
Skin
Use of contraception, history of sexually transmitted infections,
pregnancy history and outcomes, possibility of current pregnancy Pallor, bruising, petechiae, signs of hirsutism, acanthosis
nigricans, acne, scarring
Associated symptoms
External genitalia examination
Fever, chills, increasing abdominal girth, pelvic pressure or pain,
bowel or bladder dysfunction, vaginal discharge or odor Inspection of vulva, hymen and lower vagina, urethra, and anus
for abnormalities, source of bleeding, trauma, prolapse, signs of
Symptoms associated with a systemic cause of abnormal uterine cancer
bleeding/heavy menstrual bleeding
Sexual maturity rating
Obesity, CPOS, hypothyroidism, hyperprolactinemia,
hypothalamic, or adrenal disorder Speculum examination (if clinically indicated)
Further examination of vagina and cervix
Chronic medical illness
Interited bleeding disorders (coagulopathy, blood dyscrasias, Digital or bimanual examination (if clinically indicated)
platelet function disorders), systemic lupus erythematosus, Examine uterus and adnexal structures for size, masses,
connective tisssue diseases, liver disease, renal disease, tenderness
cardiovascular disease Rectal examination (if clinically indicated)
Medications If bleeding from the anus or rectum is suspected, or if risk of
Hormonal contraceptives, anticoagulants, selective serotonin concomitant pathology
reuptake inhibitors, antipsychotics, tamoxifen, herbals (e.g.,
& &&
ginseng) Adapted with permission [6 ,15 ].
Family history
Coagulation or thromboembolic disorders, hormone-sensitive
cancers may be considered (Table 6). If not already obtained,
& &&
screening for PCOS is indicated [11 ,18 ]. Pelvic
& &&
Adapted with permission [6 ,15 ]. ultrasound may be indicated if patients do not
&& &
respond to initial treatment [18 ,22 ]. Liver func-
&&
&& tion testing should be performed [18 ]. Additional
affect platelet function testing [18 ]. Testing for
bleeding disorder work up for rarer conditions
vWD can be performed while the patient is taking
should be undertaken by a hematologist, and may
combined oral contraceptives (COCs) as these typi-
&& include dysfibrinogenemia panel, fibrinolysis test-
cally only contain 30–35 mg of estrogen [18 ]. VWD
ing, coagulation factor assays, and further platelet
testing and platelet function analysis should be &&
function testing [18 ].
performed twice to confirm the results. Because iron
deficiency with or without anemia is common, first
tier testing should include either a ferritin level or an MANAGEMENT
& &
iron panel [20 ,21 ]. Additional testing during initial The goals of HMB treatment are to reduce morbidity,
evaluation may be obtained as indicated by history restore and maintain normal blood volumes, pre-
and physical exam, such as sexually transmitted vent life-threatening hemorrhage, and improve
infection screening and evaluation for PCOS quality of life [23]. There are many options effective
& &&
[11 ,18 ]. Routine ultrasound should not be in managing acute HMB (Table 7). The patient
obtained solely for the work up of HMB in adoles- may be subsequently transitioned to a maintenance
cents, as the majority of causes are nonstructural. A therapy.
&
recent study by Pecchioli et al. [22 ] showed that
only two of 156 adolescent patients were found to
have a structural abnormality, and ultrasound find- INTRAVENOUS FLUIDS AND BLOOD
ings did not alter the management plan for any of PRODUCTS
their patients. A patient may receive intravenous (i.v.) crystalloid
If the first tier results are normal, or if the patient or blood products in the acute management of
fails initial management, then second tier testing HMB if the patient demonstrates hemodynamic

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Heavy menstrual bleeding in adolescents Moon et al.

Table 6. First and second tier testing for evaluation of heavy menstrual bleeding in adolescents
First tier Pregnancy test
Hematologic tests:
CBC, reticulocyte count
Iron profile or ferritin level
Blood type and screen
Endocrine tests:
TSH, free T4
Bleeding disorder evaluation:
von Willebrand panel – von Willebrand factor antigen, factor VIII, ristocetin cofactor activity
Platelet function defects – platelet aggregation or PFA-100
Coagulation studies: PT/INR, aPTT, fibrinogen
Gynecologic tests (if indicated by patient history):
PCOS screening – FSH, LH, testosterone, DHEA-S
Sexually transmitted infection screening – Chlamydia trachomatis, Neisseria gonorrhoeae
Second tier Bleeding disorder evaluation (in consultation with hematologist):
Repeat von Willebrand disease testing (regardless of initial results), multimer analysis
Repeat platelet aggregation (if initial results are abnormal)
Dysfibrinogenimia panel – thrombin time, fibrinogen antigen, reptilase time (if thrombin time or fibrinogen abnormal)
Coagulant factor assays – Factor XI, Factor IX, Factor VII, Factor XIII
Fibrinolysis testing – euglobulin clot lysis time, a-2 antiplasmin, plasminogen activator-1 activity
Platelet glycoprotein expression/flowcytometry (based on platelet aggregation testing)
Electron microscopy – platelet granules (based on platelet aggregation testing)
Gynecologic tests:
Pelvic ultrasound – if not responding to medical therapy
PCOS screening – if not already performed
Liver function tests:
ALT, bilirubin (if prolonged PT)

aPTT, partial thromboplastin time; CBC, complete blood count; DHEA-S, dihydroepiandrosteindione sulfate; FSH, follicle stimulating hormone; INR, international
normalized ratio; LH, luteininzing hormone; PCOS, polycystic ovary syndrome; PFA, platelet function analyser; PT, prothrombin; T4, thyroxine; TSH, thyroid
stimulating hormones.
& && &&
Adapted with permission [6 ,17 ,18 ].

instability and severe anemia [23]. The need for COMBINATION ESTROGEN-
platelets is rare for AUB, however, may be necessary PROGESTERONE METHODS
in cases of severe thrombocytopenia (<50 000) or Combination estrogen and progesterone methods
&
platelet disorder [24 ]. Adolescents with clotting include the COC pill, transdermal patch, and vagi-
factor deficiencies may require clotting factor nal ring. In the treatment of HMB, dienogest/estra-
replacement with plasma-derived concentrate or diol valerate is the only COC pill that has been
&
recombinant agents [12 ]. granted approval by the US Food and Drug Admin-
istration; it effectively reduced menstrual blood loss
(MBL) when compared to placebo in a randomized
ESTROGEN &&
controlled trial [15 ]. Currently, there is not
In the acute setting of HMB, i.v. conjugated equine enough data to suggest that one type of combined
estrogen (CEE) should be considered [25]. For acute method is superior to another. Nondaily combined
HMB, i.v. CEE can be administered in 25 mg doses methods such as the patch (weekly) or the vaginal
every 4–6 h in patients who are hemodynamically ring (monthly) may improve compliance among
unstable or are unable to tolerate oral therapy adolescents and should be offered as an option
& && &&
[6 ,15 ]. i.v. CEE is routinely continued for at least [18 ]. Combined methods can also be used to ex-
24 h or until cessation of bleeding, followed by tend the interval of menstrual bleeding to a 12-week
&
transition to maintenance therapy [6 ]. cycle, or they can be taken in a continuous fashion

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Table 7. Medical management of heavy menstrual bleeding


Conjugated Combined oral Depot medroxyprogester-
equine estrogen contraceptives Progesterone-only pills one acetate

Regimen Regimens Regimens Regimens


25 mg i.v. every 50 mg ethinyl estradiol combined pill PO every 6– Medroxyprogesterone 150 mg IM injection every
4–6 h  24 h 8 h for 1 week then taper down every week to daily acetate PO 10–20 mg 12 weeks
Contraindications dosing every 6–8 h for 1 week 104 mg SQ every 12
Pregnancy 30–35 mg ethinyl estradiol combined monophasic then taper down every weeks
Venous or arterial pill PO every 6–8 h for 1 week then taper down week to daily dosing Can be given in
thromboembolic every week to daily dosing Norethindrone acetate PO combination with an oral
disease (active or Contraindications 5–10 mg PO every 6–8 h progesterone-only pill
previous) Pregnancy for 1 week then taper regimen for acute heavy
Breast cancer Breast cancer (current or past) down to daily dosing menstrual bleeding
Obesity (use with Venous thrombosis or arterial thromboembolic Contraindications Contraindications
caution) disease (active or previous) Pregnancy Pregnancy
Side-effects Known thrombogenic mutations Breast cancer (current or Breast cancer (current or
Nausea/vomiting Hypertension (>160/100 mmHg) past) past)
Spotting or SLE with valvular disease, nephritis, or APL Liver dysfunction or Liver dysfunction or
breakthrough antibodies disease disease
bleeding Headaches with aura Side-effects Multiple risk factors for
Headache Liver dysfunction or disease Irregular bleeding cardiovascular disease
Breast pain Risk factors for cardiovascular disease Amenorrhea Hypertension with vascular
VTEs Stroke Contraception disease
Stroke Major surgery with prolonged immobilization No Side-effects
IM Side-effects Decreased bone mineral
Contraception Nausea/vomiting density
No Spotting or breakthrough bleeding Irregular bleeding
Headache Amenorrhea
Breast pain Weight gain
VTEs Breast pain
Stroke Fluid retention
IM Yes
Contraception
Yes

Levonorgestrel intrauterine GnRH agonist (leuprolide


device acetate) Tranexamic acid Others

Regimen Regimens Regimens NSAIDs


Intrauterine placement every 5 3.75 mg IM every month 10 mg/kg i.v. every 6–8 h for 2– Regimen: Ibuprofen 600–800 mg
years 11.25 mg IM every 3 months 8 days every 6–8 h (best if used with
Releases 20 mg/day Can be used with add-back 1300 mg PO every 8 h for 5 days other medication)
Used for long-term management therapy to prevent side-effects Contraindications Should be avoided in patients
Contraindications Norethindrone acetate 5 mg PO Thromboembolic disease (current with suspected bleeding disorders
Pregnancy every day or past) Contraindications: pregnancy, GI
Breast cancer (current or past) Contraindications Acquired impaired color vision bleeding, IBD, severe asthma,
Liver dysfunction or disease Pregnancy Can increase thrombosis risk CKD, CVD, CHF
Sexually transmitted disease Side-effects when combined with estrogen or Side-effects: GI adverse effects
within 3 months Hot flashes progesterone therapy (bleeding, ulceration,
Pelvic inflammatory disease Sweating Side-effects perforation), worsening asthma,
Untreated cervical or uterine Vaginal dryness Headaches platelet dysfunction
cancer Trabecular bone loss with use for Nausea/vomiting Contraception: No
Unexplained abnormal uterine longer than 6 months Diarrhea Aminocaproic acid
bleeding Contraception Muscular pain 100–200 mg/kg (maximum
Large or distorted uterine cavity No Dysmenorrhea 30 g/d) i.v. or PO every 4–6 h
(should be 6–10 cm) Contraception until bleeding controlled
Side-effects No Available in oral solution
Irregular bleeding or spotting 1-deamino-8-D-arginine vasopressin
Cramping Reserved for cases when all
Breast pain hormonal and nonhormonal
Acne therapies have failed
Nausea Collaboration with a hematologist
Contraception is strongly recommended before
Yes initiation

APL, antiphospholipid; CHF, congestive heart failure; CKD, chronic kidney disease; CVD, cardiovascular disease; GI, gastrointestinal; IBD, inflammatory bowel
disease; IM, intramuscular; i.v., intravenous; SLE, systemic lupus erythematosus; SQ, subcutaneous; VTE, venous thromboembolism.
& &&
Adapted with permission [6 ,15 ].

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Heavy menstrual bleeding in adolescents Moon et al.

indefinitely. Although these extended cycle regi- cavity and lasts for 5 years; LNG-IUDs with lower
mens carry a risk of breakthrough bleeding, they doses have not been studied for treatment of
still decrease the overall MBL because of fewer bleed- HMB. Many studies have demonstrated the superi-
ing episodes when compared with monthly cycles ority of the LNG-IUD over oral MPA, norethindrone
&&
[15 ]. When transitioning off of i.v. CEE to a COC acetate, DMPA, and COCs, as there is greater
pill, various tapering regimens are available (Table 7) reduction in HMB and improved quality of life
& &&
[6 ]. Although on a tapering regimen, it is important [15 ,30]. LNG-IUD is also effective in improving
to discard the placebo pills. If an adolescent already HMB and anemia in adolescents with bleeding dis-
&
on a combined method presents with acute HMB, orders [31 ]. The quality of life and reduction in
initiating i.v. CEE or a high-dose COC taper is MBL was not significantly different between the
recommended. LNG-IUD and surgical management with endome-
trial ablation or hysterectomy in adult women
& &
[32 ,33 ].
PROGESTERONE-ONLY OPTIONS
Patients with contraindications to estrogen (Table 7)
should be offered progesterone-only options. Two GONADOTROPIN-RELEASING HORMONE
commonly used oral progestin therapies in the ado- AGONISTS
lescent population include medroxyprogesterone Gonadotropin-releasing hormone agonists such
acetate (MPA) and norethindrone acetate. In the as depoleuprolide can be used in severe cases of
acute setting, these can be prescribed as a taper chronic HMB (hematologic or oncologic-related
(Table 7) or they can be used daily once on mainte- cases), but is not reliable for use in acute HMB.
nance therapy. Strict compliance is required to pre- Within 3–4 weeks of administration, gonadotropin-
&&
vent breakthrough bleeding [18 ]. releasing hormone agonists result in endometrial
&&
Depot medroxyprogesterone acetate (DMPA) is atrophy and amenorrhea [15 ]. In addition to mood
another option which can be administered as an changes and vasomotor symptoms, loss of bone
intramuscular (IM) or subcutaneous injection. A mineral density can occur with more than 6 months
&
recent systematic review concluded that these of use [34 ]. To prevent these side-effects, add-back
&
two formulations appear to be therapeutically hormonal therapy is recommended [34 ].
&
equivalent and have similar side-effects [26 ]. The
subcutaneous route is commonly used in patients
with bleeding disorders to prevent hematoma NONHORMONAL OPTIONS
formation. DMPA can result in amenorrhea in up NSAIDs have been shown to decrease HMB in pre-
to 50% of patients and is typically given every menopausal women; however, they are not as
&
12 weeks [27 ]. The injection interval can be effective as other medical therapies [35]. Patients
reduced to every 4, 8, or 10 weeks to prevent or with suspected bleeding disorders should avoid
&&
decrease heavy breakthrough bleeding; once the NSAIDs as they can exacerbate HMB [18 ]. Tranexa-
bleeding has resolved the interval can be extended mic acid is an antifibrinolytic agent; multiple stud-
to 12 weeks. DMPA is most commonly used as ies in adult women have shown a significant
maintenance therapy. A recent pilot study in reduction of HMB with tranexamic acid when com-
&&
adults showed a cessation of acute bleeding in pared to placebo [15 ]. Oral tranexamic acid is as
2.6 days after administration of DMPA 150 mg IM efficacious as COC pills in reducing MBL and
combined with 3 days of MPA 20 mg every 8 h [28]. improving quality of life in adolescents with HMB
More studies are needed on the utility of DMPA [36]. Tranexamic acid is therefore an effective op-
for the treatment of acute and chronic AUB in tion in the treatment of HMB in the adolescent
&
adolescents. population [6 ]. Aminocaproic acid is another
Long-term maintenance options include the antifibrinolytic agent that can be used in HMB;
etonorgestrel subdermal implant and the levonor- however, it is less potent and has more side-
gestrel-releasing intrauterine device (LNG-IUD). effects [37]. Other hematologic medications such as
The etonorgestrel implant is a highly effective con- 1-deamino-8-D-arginine vasopressin or factor
traceptive option that lasts for 3 years but it has replacement may be indicated for patients with
not been well studied in the treatment for HMB specific bleeding disorders. Although 1-deamino-
&
[27 ]. Although it can result in amenorrhea in up 8-D-arginine vasopressin is used in patients with
to 24% of patients, the most common side-effect type I vWD, hemophilia A, and in women with a
is irregular bleeding which is also the most prolonged bleeding time without a bleeding disor-
common reason for discontinuation [29]. The der, it is best to consult with a hematologist prior to
& &
LNG-IUD is a device that is placed in the uterine administration [12 ,26 ].

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SURGICAL MANAGEMENT transition from adolescence to adulthood including


When medical therapy fails or in the event of a life- establishing a career, becoming independent from
threatening emergency, surgical management for their parents, and switching to an adult medical
HMB in adolescents can be considered. Fertility clinic [39]. Numerous studies have shown that
preservation should be a priority when considering adherence to treatment decreases in late childhood
&

surgical measures or invasive procedures. One and adolescence [40 ]. Motivational techniques
option is uterine balloon tamponade (Bard, Coving- implemented by parents and caregivers can improve
&

ton, GA). Studies on intrauterine balloons have adherence and self-care in adolescents [40 ].
mostly involved women with postpartum hemor-
rhage; however, these studies have demonstrated an
CONCLUSION
effective reduction in bleeding when needed emer-
&
gently [6 ]. In the adolescent population, a 30cc HMB is common in adolescents. It is important to
Foley balloon (Bard, Covington, GA) is typically have strategies for early identification of HMB
used to accommodate a smaller uterus for tampo- causes to offer the best treatments. First-line treat-
&
nade [6 ]. In older women, dilation and curettage ments focus on medical management, both hor-
has not been effective in treating HMB and is also monal and nonhormonal options, rather than
not recommended for treatment for HMB manage- invasive interventions as maintenance of fertility
&&
ment, especially in adolescents [18 ]. Endometrial is critical in this age group.
ablation destroys the endometrium through various
methods, and studies have shown that endometrial Acknowledgements
ablation successfully reduces HMB in postmeno- None.
pausal women; however, this is not a recommended
strategy in adolescents because of fertility affects Financial support and sponsorship
and because of high failure rates in young women None.
&
[27 ]. Last, a hysterectomy is a major surgical pro-
cedure, which removes the uterus and resolves Conflicts of interest
HMB. To maintain fertility in the adolescent, sur- There are no conflicts of interest.
gery should be avoided unless absolutely necessary
&
in life-threatening circumstances [6 ].
REFERENCES AND RECOMMENDED
READING
MULTIDISCIPLINARY APPROACH Papers of particular interest, published within the annual period of review, have
been highlighted as:
Young women with bleeding disorders may be inade- & of special interest
&& of outstanding interest
quately treated at the time of menarche despite hav-
ing a diagnosis. A retrospective review of adolescents 1. Karaman K, Ceylan N, Karaman E, et al. Evaluation of the hemostatic disorders
in adolescent girls with menorrhagia: experiences from a tertiary referral
with bleeding disorders showed that the majority of &

hospital. Indian J Hematol Blood Transfus 2016; 32:356–361.


prepubertal girls did not discuss with their provider The study evaluated the prevalence of bleeding disorders in adolescent women
referred to a pediatric hematology clinic, with the most common disorders being
any treatment plans, including whether they needed vWD and platelet function disorders.
more than one medication to control HMB following 2. Esen İ, Oğuz B, Serin HM. Menstrual characteristics of pubertal girls: a
&& questionnaire-based study in Turkey. J Clin Res Pediatr Endocrinol 2016; 8:
menarche [38 ]. To prevent HMB complications, &

192–196.
adolescents with bleeding disorders should be man- The survey of high school girls highlights the effect of menstrual disorders such as
dysmenorrhea and heavy bleeding on quality of life.
aged in a multidisciplinary setting in consultation 3. Nur Azurah AG, Sanci L, Moore E, Grover S. The quality of life of adolescents
with a pediatric gynecologist and hematologist before with menstrual problems. J Pediatr Adolesc Gynecol 2013; 26:102–108.
4. Nooh AM, Abdul-Hady A, El-Attar N. Nature and prevalence of menstrual
they reach menarche; this collaboration should also disorders among teenage female students at Zagazig University, Zagazig,
&&
be continued beyond menarche [38 ]. Consultation Egypt. J Pediatr Adolesc Gynecol 2016; 29:137–142.
5. ACOG Committee Opinion No. 651. Menstruation in girls and adolescents:
with a hematologist at the time of initial presentation && using the menstrual cycle as a vital sign. Obstet Gynecol 2015; 126:
in a patient with HMB and potentially unknown e143–e146.
The updated opinion statement by American College of Obstetricians and Gy-
bleeding disorder is important, particularly for diffi- necologists emphasizes the importance of early identification of menstrual ab-
cult cases which are unresponsive to medical therapy normalities for long-term health and quality of life. Recommendations include
& anticipatory guidance about normal menses and what to expect with menarche
[6 ]. To improve clinical outcomes, a multidisciplin- beginning at age 7–8 years, as well as asking about last menstrual period and
&&
ary approach is recommended [17 ]. menstrual pattern at every preventive care/comprehensive visit once menarche
occurs. This paper also contains several useful figures outlining normal menses
and abnormal menses that may require evaluation.
6. Haamid F, Sass AE, Dietrich JE. Heavy menstrual bleeding in adolescents.
TRANSITION TO ADULTHOOD & J Pediatr Adolesc Gynecol 2017; 30:335–340.
The opinion paper published by the North American Society for Pediatric and
Young adults with bleeding disorders or chronic Adolescent Gynecology reviews the diagnosis and treatment of HMB particularly
medical conditions face unique challenges in their in the adolescent population, and includes helpful tables for quick reference.

8 www.co-obgyn.com Volume 29  Number 00  Month 2017

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GCO 290504

Heavy menstrual bleeding in adolescents Moon et al.

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ment of patients in this age group. care.

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