CME CREDIT NOW AVAILABLE-1.0 AMA PRA Category 1 Credit FOR EACH ISSUE (2 ARTICLES)!!!!!!
by Mona Kulkarni
Case: 15-year-old otherwise healthy adolescent presents to your office complaining of a menstrual cycle lasting longer than 10 days. She has been changing her sanitary pads hourly at times and passing heavy clots. Now she’s feeling a bit dizzy.
What is the work up that we need to do? The Heavy Menstrual Bleeding guideline was created by our team to help guide us in the evaluation.
Heavy Menstrual Bleeding (HMB) is one of the most common adolescent gynecology complaints we see in the ED. The differential diagnosis is broad including anovulatory cycles, hypothyroidism and underlying bleeding disorders (up to 20% of cases). The importance of early recognition and determination of the underlying cause can positively impact the teen’s quality of life, school attendance and sports participation.
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A typical menses in the adolescent should occur every 21- 45 days, lasting less than 7 days, using less than 6 pads or tampons per day, with average blood loss of 30-40 ml. A cycle lasting longer than 7 days, using 1 pad or tampon every hour, or soaking thru more than 6 pads or tampons per day is considered to be pathologic and may lead to iron deficiency anemia, headaches, fatigue and pallor.
The cause may not always be easy to determine but include:
- Immature hypothalamic-pituitary-ovarian (HPO) axis resulting in anovulation
- Polycystic ovarian syndrome (hyperandrogenism and anovulation)
- Thyroid problems such as hypothyroidism
2 Bleeding Disorders (Important to ask Family History)
- Von Willebrand disease
- Platelet disorders (such as ITP)
- Infections, such as STI or other pelvic infections
- Structural Problems
- Duplication of the Mullerian system and double vagina
- Uterine polyps or fibroids (less common in adolescents)
- Cancer (rare in teens)
- Medications (anticoagulation)
6 ***Pregnancy related problems- Pregnancy must be excluded in all those with unexplained bleeding even those who deny sexual activity.
The presentation can vary widely from complaints of fatigue due to the iron deficiency anemia to syncope. Our guideline includes a validated screening tool used in the adult population to guide practitioners when to order various screening labs to better identify an underlying bleeding disorder. Though not validated in teenagers, it may help pediatricians decide when to order further testing as well. Important questions include:
-“ flooding” or soaking thru one or more sanitary pads or tampons every hour for
– needing to wake up to change pads at night
– need to use double sanitary protection to control flow (tampon + pad)
– menstrual cycle lasting longer than a week
– symptoms such as fatigue, HA, lightheadedness or SOB
– passing large blood clots (> 1 cm)
– family history of bleeding disorder
– easy bruising, gum bleeding, or nose bleeds
If there is a concern for further evaluation of the patient based on symptoms or history, we recommend a thorough laboratory evaluation including CBC, Ferritin, PT/PTT, Fibrinogen, von-Willebrand panel (including vWB antigen, ristocetin cofactor, and factor 8). Platelet function assay can also be considered. Complete Metabolic Profile, baseline thyroid studies and urine for infections and STI are also included in the guideline. A pelvic ultrasound to evaluate to structural causes of HMB may also be considered.
After determining whether the patient is mildly anemic (Hgb >9), Moderately anemic (Hgb 7-8) or severely anemic (Hgb < 7), the guideline helps suggest management for these teenagers. If admitted, the patient may receive IV estrogen to help stop the bleeding and then start an OCP to manage the cycle as an outpatient. Other combined hormone therapies, progesterone only, and anti-fibrinolytic agents are available to stop bleeding depending on the presentation and patient co-morbidities.
HMB is a common complaint in adolescent women. The differential is broad and requires a low threshold for investigation particularly for bleeding disorders. We are fortunate to have our Children’s Physician Group Pediatric and Adolescent Gynecologist, Dr. Krista Childress and her team to assist in the treatment of our patients who present with heavy menstrual bleeding and are invaluable in the management of these patients. Please call 404-785-6895 to refer a patient.