By Amy Pattishall
apattis@emory.edu

Heavy Menstrual Bleeding Guideline

Children’s Healthcare of Atlanta Emergency Department (ED) implemented one of its newest guidelines, for Heavy Menstrual Bleeding (HMB), in August 2016. This guideline represents a collaboration of several specialties, including Pediatric Emergency Medicine, Urgent Care, Hematology, Adolescent Medicine and Gynecology, with the goals of:

* Establishing a uniform process for evaluation and management of adolescents with HMB

* Reducing repeat visits to the ED for the same concern

* Expediting diagnosis of congenital bleeding disorders

* Improving the quality of life for adolescents experiencing HMB

* Providing improved opportunities for adolescent and gynecology follow up care

Why is such a guideline necessary?

Many adolescents with HMB present to the ED for evaluation, whether they are symptomatic or not. Evidence shows that patients presenting with HMB receive variable workups, potentially delaying diagnosis of bleeding disorders. This guideline helps to ensure that all adolescents at risk for a bleeding disorder receive appropriate laboratory evaluation and follow up with hematology or gynecology. HMB can also cause chronic iron deficiency anemia and affect adolescents’ quality of life. We hope the guideline will help improve patients’ quality of life by standardizing treatment for HMB.

Which patients are included in the guideline?

Any menstruating female with concern for HMB meets inclusion criteria. Patients with previously diagnosed bleeding disorders are excluded. The guideline incorporates an evidence-based screening tool to determine if laboratory workup for a congenital bleeding disorder is necessary, which is considered positive if the patient answers “yes” to any of the screening questions.

Screening Questions (Adapted from Claire Phillip Screening tool; AMJOG 2011):

1. On average does your period last 7 or more days?

2. Do you experience “flooding” or overflow bleeding through your tampon or pad?

3. Do you need to change your pad or tampon more than every 1-2 hours at times during your period?

4. Have you ever been treated (PO iron, IV iron, blood transfusions) for iron deficiency anemia in the past?

5. Do you have a family history of a bleeding disorder?

6. Have you had excessive bleeding with a dental extraction or dental surgery?

7. Have you had excessive bleeding with a miscarriage or following delivery of a child?

How do providers use the guideline?

The guideline stratifies patients based on severity of anemia and symptoms to help determine need for admission and IV versus oral medications. Recommendations on hormone and adjunct treatment (iron, anti-emetics, stool softeners) are included, as well as contact numbers for follow up at Emory Fellows’ Family Planning/Gynecology clinic, the Adolescent Medicine clinic at Hughes Spalding, and the CHOA Hematology clinic.

The HMB guideline, along with the full evidence summary, can be accessed on the CHOA Physician Portal: md.choa.org.