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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.
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
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:
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.
 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
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
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
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
patients fill out screening surveys or bleeding
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
Tenderness, distension, striae, palpable masses, hepatomegaly
Sexual and reproductive history
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
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

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 ].
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
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 ].
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, &

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 Volume 29  Number 00  Month 2017

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CE: Alpana; GCO/290504; Total nos of Pages: 9;
GCO 290504

Heavy menstrual bleeding in adolescents Moon et al.

7. Sanchez J, Andrabi S, Bercaw JL, Dietrich JE. Quantifying the PBAC in a 23. Wilkinson JP, Kadir RA. Management of abnormal uterine bleeding in
pediatric and adolescent gynecology population. Pediatr Hematol Oncol adolescents. J Pediatr Adolesc Gynecol 2010; 23(6 Suppl):S22–S30.
2012; 29:479–484. 24. Rajpurkar M, O’Brien SH, Haamid FW, et al. Heavy menstrual bleeding as a
8. Sanders YV, Fijnvandraat K, Boender J, et al. Bleeding spectrum in children & common presenting symptom of rare platelet disorders: illustrative case
& with moderate or severe von Willebrand disease: relevance of pediatric- examples. J Pediatr Adolesc Gynecol 2016; 29:537–541.
specific bleeding. Am J Hematol 2015; 90:1142–1148. The authors of this study present two cases of platelet function disorders and their
The study highlights the pediatric-specific bleeding symptoms experienced by HMB at time of menarche.
patients with vWD, including menorrhagia, to aid with earlier recognition of this 25. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment
particular bleeding disorder. of dysfunctional uterine bleeding: a double-blind randomized control study.
9. Dietrich JE, Yee DL, Santos XM, et al. Assessment of an electronic interven- Obstet Gynecol 1982; 59:285–291.
& tion in young women with heavy menstrual bleeding. J Pediatr Adolesc 26. Davies J, Kadir RA. Heavy menstrual bleeding: an update on management.
Gynecol 2017; 30:243–246. & Thromb Res 2017; 151(Suppl 1):S70–S77.
The study demonstrates how providers can utilize electronic media to enhance The article offers a thorough review of HMB in adult women, including definitions,
patient care through more accurate menstrual tracking and improved medication assessments, cause, evaluation, and management.
compliance. 27. Dragoman MV, Gaffield ME. The safety of subcutaneously administered depot
10. Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on & medroxyprogesterone acetate (104mg/0.65mL): a systematic review. Contra-
Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes ception 2016; 94:202–215.
of abnormal uterine bleeding in nongravid women of reproductive age. Int J The review article analyzed 14 studies on DMPA which suggested that both IM and
Gynaecol Obstet 2011; 113:3–13. SC formulations are therapeutically equivalent with similar side-effects; however,
11. Maslyanskaya S, Talib HJ, Northridge JL, et al. Polycystic ovary syndrome: the studies that were analyzed did not include adolescents.
& an under-recognized cause of abnormal uterine bleeding in adolescents ad- 28. Ammerman SR, Nelson AL. A new progestogen-only medical therapy for
mitted to a children’s hospital. J Pediatr Adolesc Gynecol 2017; 30:349–355. outpatient management of acute, abnormal uterine bleeding: a pilot study. Am
The research study found both PCOS and endometritis as common causes of J Obstet Gynecol 2013; 208:499.e1–499.e5.
heavy bleeding leading to hospital admission, and should be considered in the 29. Bhatia P, Nangia S, Aggarwal S, Tewari C. Implanon: subdermal single
initial work up based on patient history. rod contraceptive implant. J Obstet Gynaecol India 2011; 61:422–
12. Kulkarni R. Improving care and treatment options for women and girls with 425.
& bleeding disorders. Eur J Haematol 2015; 95(Suppl 81):2–10. 30. Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or progesto-
The review article increases awareness of bleeding disorders, proposes a manage- gen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane
ment algorithm with consideration of fertility preservation, and it emphasizes the Database Syst Rev 2015; CD002126.
importance of multidisciplinary approach in the treatment of HMB. 31. Adeyemi-Fowode OA, Santos XM, Dietrich JE, Srivaths L. Levonorgestrel-
13. Dı́az R, Dietrich JE, Mahoney D, et al. Hemostatic abnormalities in young females & releasing intrauterine device use in female adolescents with heavy menstrual
with heavy menstrual bleeding. J Pediatr Adolesc Gynecol 2014; 27:324–329. bleeding and bleeding disorders: single institution review. J Pediatr Adolesc
14. Ferreira M, Barsam S, Patel JP, et al. Heavy menstrual bleeding on rivarox- Gynecol 2016; 30:479–483.
& aban. Br J Haematol 2016; 173:314–315. The retrospective study showed that the LNG-IUD was an effective treatment
The study highlights the effects that direct oral anticoagulant medications can have option with minimal complications in thirteen adolescent patients with bleeding
on menses. disorders or HMB.
15. Bradley LD, Gueye NA. The medical management of abnormal uterine bleed- 32. Health Quality Ontario. Levonorgestrel-releasing intrauterine system (52mg)
&& ing in reproductive-aged women. Am J Obstet Gynecol 2016; 214:31–44. & for idiopathic heavy menstrual bleeding: a health technology assessment. Ont
The review article recognizes medical management as the first-line approach in the Health Technol Assess Ser 2016; 16:1–119.
treatment of AUB in women. It thoroughly reviews hormonal and nonhormonal The article is a systematic review of randomized controlled trials comparing LNG-
treatment options and it includes useful tables for reference. The majority of the IUD with other treatment options and concluded that the LNG-IUD is an effective
medical options described in this article have been studied and have been used and cost-effective treatment option in HMB management.
effectively in the adolescent population. 33. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy
16. Huguelet PS, Buyers EM, Lange-Liss JH, Scott SM. Treatment of acute & for heavy menstrual bleeding. Cochrane Database Syst Rev 2016;
& abnormal uterine bleeding in adolescents: what are providers doing in various CD003855.
specialties? J Pediatr Adolesc Gynecol 2016; 29:286–291. The article reviewed the current literature comparing outcomes of medical and
The study compared the evaluation and treatment of adolescents with AUB in the surgical intervention of women with HMB, and found that the levonorgestrel
emergency setting between providers from different specialties, and highlights the intrauterine device, hysterectomy, and endometrial surgery were all effective at
wide ranging inconsistencies in documenting menstrual history, obtaining basic reducing heavy bleeding.
laboratory work up, and treatment options. 34. Quinn SM, Louis-Jacques J. Menstrual management and reproductive con-
17. Zia A, Lau M, Journeycake J, et al. Developing a multidisciplinary Young & cerns in adolescent and young adult women with underlying hematologic or
&& Women’s Blood Disorders Program: a single-centre approach with guidance oncologic disease. Curr Opin Pediatr 2016; 28:421–427.
for other centres. Haemophilia 2016. doi:10.1111/hae.12836. The article reviews the management of HMB in adolescents, including mens-
The study highlights the improved care provided in a collaborative setting, and trual suppression, fertility preservation, and contraception in this type of patient
details the process of creating a multidisciplinary clinic for adolescents with HMB. population.
They provide examples of the evaluation and treatment protocols they use to 35. Lethaby A, Duckitt K, Farquhar C. Nonsteroidal anti-inflammatory drugs
standardize patient care and ensure optimal outcomes. for heavy menstrual bleeding. Cochrane Database Syst Rev 2013;
18. Zia A, Rajpurkar M. Challenges of diagnosing and managing the adolescent CD000400.
&& with heavy menstrual bleeding. Thromb Res 2016; 143:91–100. 36. Srivaths LV, Dietrich JE, Yee DL, et al. Oral tranexamic acid versus combined
The review poses several clinical questions regarding adolescents with HMB, oral contraceptives for adolescent heavy menstrual bleeding: a pilot study.
reviews the current literature available to answer these questions, and highlights J Pediatr Adolesc Gynecol 2015; 28:254–257.
areas of limited knowledge for proposed future research studies. 37. James AH, Kouides PA, Abdul-Kadir R, et al. Evaluation and management of
19. Mills HL, Abdel-Baki MS, Teruya J, et al. Platelet function defects in adoles- acute menorrhagia in women with and without underlying bleeding disorders:
cents with heavy menstrual bleeding. Haemophilia 2014; 20:249–254. consensus from an international expert panel. Eur J Obstet Gynecol Reprod
20. Cooke AG, McCavit TL, Buchanan GR, Powers JM. Iron deficiency anemia in Biol 2011; 158:124–134.
& adolescents who present with heavy menstrual bleeding. J Pediatr Adolesc 38. Dowlut-McElroy T, Williams KB, Carpenter SL, Strickland JL. Menstrual
Gynecol 2016; 30:247–250. && patterns and treatment of heavy menstrual bleeding in adolescents with
The study demonstrated that initial treatment of iron deficiency anemia in adoles- bleeding disorders. J Pediatr Adolesc Gynecol 2015; 28:499–501.
cents with HMB is frequently suboptimal. The retrospective study showed that almost half of the patients with bleeding
21. Johnson S, Lang A, Sturm M, O’Brien SH. Iron deficiency without anemia: a disorders had HMB, patients with vWD had prolonged menses, and over half of the
& common yet under-recognized diagnosis in young women with heavy men- patients failed initial treatment. The study emphasizes the importance of a multi-
strual bleeding. J Pediatr Adolesc Gynecol 2016; 29:628–631. disciplinary approach that is initiated prior to menarche.
The study highlights the importance of screening for iron deficiency in adolescents 39. Quon D, Reding M, Guelcher C, et al. Unmet needs in the transition to
with HMB, despite their hemoglobin levels, as iron deficiency can occur in the adulthood: 18 to 30-year-old people with hemophilia. Am J Hematol 2015;
absence of anemia. 90(Suppl 2):S17–S22.
22. Pecchioli Y, Oyewumi L, Allen LM, Kives S. The utility of routine ultrasound in 40. Bérubé S, Mouillard F, Amesse C, Sultan S. Motivational techniques to
& the diagnosis and management of adolescents with abnormal uterine bleed- & improve self-care in hemophilia: the need to support autonomy in children.
ing. J Pediatr Adolesc Gynecol 2016; 30:239–242. BMC Pediatr 2016; 16:4.
This study evaluated the utility of performing routing ultrasound as part of the work The article reviews strategies to improve motivation in children and provides
up for HMB in adolescents, and found that ultrasound does not change manage- a table of examples of different communication approaches to promote self-
ment of patients in this age group. care.

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