Dr Brooke O’Brien’s recent article for QML is focussed on educating GPs and other women’s health professionals on the management of menstrual bleeding disorders in young women. For more information, contact Northside Gynaecology.
Heavy menstrual bleeding (HMB) is a common gynaecological complaint among adolescents with up to 40% having experienced HMB. In the majority of cases, it is an immaturity of the process of ovulation that leads to irregular, either more frequent or longer cycles, and prolonged menstruation. In young women with HMB, particularly in those who are presenting with anaemia and those who are not responding to the usual hormonal attempts to manage HMB, it is prudent to exclude the presence of an underlying bleeding disorder which are not uncommon.
History should include an assessment of the duration of menses and the pattern of the menstrual cycle. An assessment quantifying the bleeding should be attempted with simple questions such as “how often would you need to change a pad or tampon?”. Adolescents presenting with HMB should be specifically asked about symptoms of anaemia, including fatigue, difficultly concentrating on homework and participating in sports, shortness of breath, and palpitations. Any history of easy bruising, bleeding after dental or surgical care, or family history of bleeding or bleeding disorders should also be sought.
In adolescents with heavy or prolonged menstrual bleeding, it is important to check the full blood count, iron studies[MOU1] , and in some cases screen for abnormalities in blood clotting or bleeding disorders, such as von Willebrand disease or platelet function disorders. In some cases, it is necessary to do a transabdominal pelvic ultrasound.
Sometimes a conservative watch and wait approach is appropriate. However, early and appropriate management of menses in adolescents with HMB is of considerable benefit in preventing morbidity such as iron deficiency and anaemia. The combined oral hormonal pill, progesterone-only hormonal options (Provera or Primolut), and non-hormonal medications to reduce bleeding such as Tranexamic acid (TEXA) are considered first-line treatment. Once regular menses is established on oral hormonal medications, the adolescent may bi-cycle or tri-cycle to reduce menstrual loss. In some cases, where the goal is menstrual suppression, Depot Provera or Mirena IUS can be used. The levonorgestrel intrauterine system (Mirena, Bayer) has been found to be safe and highly effective at achieving menstrual suppression in adolescents with HMB; however, it should only be inserted in consultation with a Paediatric and Adolescent Gynaecologist under general anaesthetic.
In approaching the adolescent with HMB, education regarding the normal physiology and anatomy of the menstrual cycle should be discussed in detail, with aid of diagrams. When prescribing medication, an understanding of how medications work will improve compliance, and hence the efficacy of treatment. It should be checked that the adolescent and/or her parents/carer understand the instructions, which may require them to be provided in writing.
Iron deficiency and/or anaemia contributes to morbidity seen in this population, and addressing this contributes to the wellbeing of the adolescent with HMB. It is very important to be specific when prescribing iron replacement, because there exist several over-the-counter supplements that have very low iron content and provide little benefit. I routinely recommend a combined iron formation such as Ferrograd C (Mylan Health) containing ferrous sulfate 325mg (equivalent to 105mg of elemental iron) and sodium ascorbate (equivalent to 500mg or ascorbic acid or vitamin C) for improved absorption, at a dose of one tablet daily. For adolescents who are unable to tolerate oral iron supplementation due to gastrointestinal upset or other symptoms, the availability of newer, safer, more cost-effective intravenous iron preparations such as iron carboxymaltose (Ferinject, Mylan Health) may be used.
In the majority of adolescents with heavy menstrual bleeding, effective management can be accomplished with either hormonal medications alone or in conjunction with antifibrinolytic agents. Management should be tailored to the needs of the individual adolescent, and in cases not responding to routine 1st line hormonal management such as the COCP and/or TEXA, where there is a significant anaemia, or concern regarding a bleeding disorder, involvement of a Paediatric and Adolescent Gynaecologist and/or haematologist would be appropriate.
- O’Brien B, Mason J, Kimble R. Bleeding Disorders in Adolescents with Heavy Menstrual Bleeding: The Queensland Statewide Paediatric and Adolescent Gynaecology Service. J Pediatr Adolesc Gynecol 2019; 32(2): p.122-127.
- Alaqzam TS, Stanley AC, Simpson PM, Flood VH, Menon S. Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2018. 31(5): p. 451-458.
- , Santos XM, Dietrich JE, SrivathL. Levonorgestrel-Releasing Intrauterine Device Use in Female Adolescents with Heavy Menstrual Bleeding and Bleeding Disorders: Single Institution Review. J Pediatr Adolesc Gynecol 2017. 30(4): p479-483