Heavy Menstrual Bleeding

Column Author: Kelsey Gavin, DO | Resident PGY3

Column Editor: Angela D. Etzenhouser, MD, FAAP | Associate Director, Pediatric Residency Program Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Heavy menstrual bleeding (HMB) can be overlooked as a regular part of puberty or menses, but if left untreated can cause significant medical complications such as anemia, fatigue and even reduced quality of life. Initial assessment for HMB, along with appropriate evaluation and long-term management, should be a regular part of every health care provider’s arsenal given the positive impact that care can provide to a patient’s quality of life.

While reaching menarche and achieving regular menstruation is a critically important developmental milestone, the presence of abnormal uterine bleeding can cause significant distress to the adolescent female.¹ Abnormal uterine bleeding (AUB) is the preferred terminology to describe any alteration in menstrual frequency, regularity and menses volume per the Federation of International Gynecology and Obstetrics, while HMB describes the perception of increased menstrual volume.² The true quantification of blood loss can be difficult to assess for both providers and patients. Although tools such as the “pictorial blood assessment chart” have been used in adult women, there is limited literature regarding use in adolescent females.²

The most common causes of HMB in adolescent females include ovulatory dysfunction and coagulopathy.¹ With a wide variety in management within these two categories, initial diagnostic evaluation remains critically important. A patient who presents with concerns for hemodynamic instability should be transferred to a higher level of care or to emergent care with appropriate consultation to gynecology and heme-onc services.

The initial evaluation of HMB in an adolescent female who is stable should include a detailed menstrual history. Key components of a menstrual history should include the presence or absence of heavy bleeding at menarche, prolonged menstrual bleeding lasting more than eight days, frequent menstrual bleeding including cycles <24 days, flooding or heavy leaking into clothing, passage of clots (particularly if >2 cm diameter), increased menstrual hygiene product use including saturating or changing pads or tampons every 120 minutes or less, and a history of iron deficiency anemia.¹

Another crucial component to evaluation of HMB includes a bleeding history. The provider should assess for spontaneous episodes of bleeding lasting > 10 minutes, including epistaxis (in the absence of allergic rhinitis), gingival/oral bleeding (in the absence of gingivitis), and cutaneous bleeding from superficial lacerations or abrasions. The provider should also ask about any muscle or joint bleeds, postpartum hemorrhage, and excessive bleeding requiring blood transfusion.¹ An assessment of family history of bleeding abnormalities with a family menstrual history should also be obtained if available.¹ A patient who has experienced any of the above with a positive family history of a bleeding disorder should be considered high risk for a bleeding disorder.

Should your patient be at risk for bleeding disorder, initial laboratory evaluation should include PT/aPTT, fibrinogen, ferritin and TSH. In all cases with risk of bleeding disorder, pelvic ultrasonography should be considered the initial imaging modality of choice following discussion with gynecology.

Admission is warranted if the patient requires transfusion or has hemodynamic instability, or if a follow-up cannot be ensured. The gynecology service should be consulted if the patient has a hemoglobin < 8, is symptomatic for anemia, or is concerning for a pelvic mass. If the patient does not meet criteria for admission or gynecology evaluation, outpatient treatment options should be considered with close follow-up. Non-hormonal medications should be considered as first-line agents for initial outpatient medical management. These medications include ibuprofen, tranexamic acid and iron supplementation. If using hormonal therapies, progesterone only vs. combined estrogen and progesterone agents can be considered. All patients with HMB should be evaluated by their PCP within two weeks of this initial evaluation, with planned gynecology evaluation within two months. Referral to heme-onc should be considered in patients who are at risk for bleeding disorder.

HMB is a complex and multifaceted component of adolescent care. For more details on laboratory evaluation and triaging recommendations in the evaluation of HMB, please visit Children’s Mercy’s Evidence Based Practice Clinical Practice Guideline for Evaluation and Management of Heavy Menstrual Bleeding: https://www.childrensmercy.org/health-care-providers/evidence-based-practice/cpgs-cpms-and-eras-pathways/heavy-menstrual-bleeding-care-process-model/

References:

• Borzutzky C, Jaffray J. Diagnosis and management of heavy menstrual bleeding and bleeding disorders in adolescents. JAMA Pediatr.2020;174(2):186-194. doi:10.1001/jamapediatrics.2019.5040

• Haamid F, Sass AE, Dietrich JE. Heavy menstrual bleeding in adolescents. J Pediatr Adolesc Gynecol. 2017;30(3):335-340. doi:10.1016/j.jpag.2017.01.002