ACOG Guidelines at a Glance: Heavy Menstrual Bleeding in Adolescents

Abstract: Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life. If obstetrician-gynecologists suspect that a patient has a bleeding disorder, they should work in coordination with a hematologist for laboratory evaluation and medical management.

Evaluation of adolescent girls who present with heavy menstrual bleeding should include assessment for anemia from blood loss, including serum ferritin, the presence of an endocrine disorder leading to anovulation, and evaluation for the presence of a bleeding disorder. Physical examination of the patient who presents with acute heavy menstrual bleeding should include assessment of hemodynamic stability, including orthostatic blood pressure and pulse measurements.

The first-line approach to acute bleeding in the adolescent is medical management; surgery should be reserved for those who do not respond to medical therapy. Use of antifibrinolytics such as tranexamic acid or aminocaproic acid in oral and intravenous form may be used to stop bleeding. Nonmedical procedures should be considered when there is a lack of response to medical therapy, if the patient is clinically unstable despite initial measures, or when severe heavy bleeding warrants further investigation, such as an examination under anesthesia.

After correction of acute heavy menstrual bleeding, maintenance hormonal therapy can include combined hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices. Obstetrician–gynecologists can provide important guidance to premenarchal and postmenarchal girls and their families about issues related to menses and should counsel all adolescent patients with a bleeding disorder about safe medication use and future surgical considerations.

Used with permission. Copyright the American College of Obstetricians and Gynecologists.

Commentary: Practical guidance on managing teens with HMB

By Paula J. Adams Hillard, MD

The American College of Obstetricians and Gynecologists (ACOG) has released a Committee Opinion that addresses a relatively common clinical scenario: that of a teen with excessive menstrual bleeding who may present acutely with syncope or with ongoing prolonged and heavy bleeding.¹

The document highlights the definition of heavy menstrual bleeding (HMB) as excessive menstrual blood loss that interferes with a woman’s physical, social, emotional, or material quality of life. While adolescents in the first few years after menarche (the first gynecologic years) typically have anovulatory cycles that may be somewhat irregular, it is not true that “anything goes” in terms of menstrual bleeding. Adolescent menstrual cycles typically occur in the range of every 21 to 45 days, lasting 7 days or fewer.²

The Committee Opinion provides a screening tool to aid in identifying teens who require further evaluation to determine an underlying cause of HMB, with specific questions about their menstrual history and any other factors that would suggest a bleeding disorder such as von Willebrand disease.

Tell-tale signs include soaking the bed sheets and bleeding through a pad or tampon in 2 hours or less.  Studies suggest that HMB presenting at menarche is particularly likely to be associated with a bleeding disorder such as von Willebrand disease, most commonly, but also platelet function disorders, thrombocytopenia, and clotting factor deficiencies. 

The adolescent who presents with acute heavy bleeding will require an initial assessment of hemodynamic stability, labs to rule out pregnancy and bleeding disorders, testing for sexually transmitted infections (STI) if a confidential history reveals sexual activity, and consideration of testing for underlying causes of anovulation, as indicated. The next decision in the decision tree is whether inpatient admission is warranted, followed typically by hormonal management, traditionally with a combined oral contraceptive (COC) taper.

The authors of the Committee Opinion also note the use of a high-dose progestin taper if there are contraindications to estrogens, although in my own practice, I have switched entirely to use of high-dose progestins followed by a taper, as it is much better tolerated than high-dose COCs. 

Typical pitfalls that I see in my referral practice include failure to obtain lab testing for bleeding disorders (prothrombin time, partial thromboplastin time, international normalized ratio, fibrinogen, von Willebrand factor activity and antigen, and Factor VIII activity) prior to initiation of hormonal therapy, making interpretation of coagulation studies and von Willebrand testing less accurate if they are tested while the patient is taking hormonal therapy. 

The other error that I see frequently is the attempt to stop prolonged, presumably anovulatory, bleeding using a traditional dosing of a one pill/day regimen. This dosing is typically not sufficient to stop the bleeding. The pathophysiology of anovulatory bleeding includes presence of an excessively proliferated or a disordered proliferative endometrium. High-dose hormonal therapy is required to produce cessation of anovulatory bleeding initially, but then a taper and temporary cessation of hormonal treatment is required to shed the thickened endometrium.

Following this withdrawal bleeding, which results in shedding of the abnormally proliferated endometrium, maintenance therapy can be initiated with a once- daily pill, given either continuously (recognizing that breakthrough bleeding may still occur) or allowing withdrawal bleeding on a periodic basis.

Another management problem that I see in my office is failure to initiate oral iron therapy after an acute bleeding episode, or failure to monitor for problems with adherence to oral iron. 

The approach to evaluation of an adult with HMB is modified in adolescents. Per the ACOG Committee Opinion, a speculum examination typically is not required for an adolescent with HMB. Because structural causes of HMB are rare in teens (the PALM causes of HMB in the PALM-COEIN schema³), a pelvic ultrasound is not routinely required, and if deemed necessary because of lack of response to therapy, can typically be performed with a transabdominal approach rather than transvaginal ultrasonography. 

Additional pearls that are provided in the ACOG document include the reminder that antifibrinolytics such as tranexamic acid can be used.  Although the document cites the prescribing information that lists concurrent use of COCs as a contraindication for these drugs because of a theoretical increased risk of thrombosis, the Committee Opinion notes that data are sparse and these drugs have been used concomitantly when other therapies have been insufficient to control bleeding. 

Finally, non-medical options such as use of an intrauterine Foley catheter, suction evacuation of intrauterine clots, or a decidual cast may be appropriate on rare occasions, and when an examination under anesthesia is required, a levonorgestrel intrauterine device may be provided for ongoing therapy of HMB. 

Clinicians in practice will undoubtedly see adolescents presenting acutely with HMB. The guidance provided by the ACOG Committee Opinion is well worth noting as a practical reference and guide. 

Dr. Hillard is Professor, Department of Obstetrics and Gynecology, Stanford University School of Gynecology and Director, Gynecology, Lucile Packard Children’s Hospital, Stanford, Calif. She is also a member of the Contemporary OB/GYN Editorial Board.

References:

.           Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019;134(3):e71-e83.

2.         ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol. 2015;126(6):e143-146.

3.         Munro MG, Critchley HO, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertil Steril. 2011;95(7):2204-2208, 2208.e2201-2203.