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GCO 290504

REVIEW

CURRENT
OPINION Evaluation and management of heavy menstrual
bleeding in adolescents
Lisa M. Moon, Gisselle Perez-Milicua, and Jennifer E. Dietrich

Purpose of review
Heavy menstrual bleeding (HMB) is a common condition in women of reproductive age; however,
adolescents with this issue present unique challenges in both diagnosis and management. Much of
the research into this topic focuses on the adult population, with variable applicability to
adolescents. There are currently no standard guidelines for the work up and treatment of adolescents
with HMB.
Recent findings
Current research into this topic has explored the utilization of standardized protocols in the evaluation of
HMB in adolescents, the efficacy of various hormonal, nonhormonal, and surgical treatment modalities,
and the benefits of a multidisciplinary approach. Recent literature has focused on adolescents found to
have an underlying bleeding disorder, recommending more comprehensive bleeding disorder work up to
identify these patients in a timely manner and initiate effective treatment plans.
Summary
Providers in the primary care setting should be aware of the definitions for normal menses, and be able to
recognize abnormal bleeding and HMB. Early recognition of HMB in adolescents can then lead to
appropriate diagnosis of underlying disorders, and current research has proposed standard protocols to
assist with the evaluation, ultimately leading to effective long-term management into adulthood.
Video abstract
http://links.lww.com/COOG/A40
Keywords
abnormal uterine bleeding, adolescents, bleeding disorder, heavy menstrual bleeding

INTRODUCTION 90% of cycles still fall within this range. Further

The prevalence of heavy menstrual bleeding (HMB) evaluation is warranted when cycles fall outside this
&&

is 10–20% in adult women, but higher in adoles- range [5 ]. Bleeding should last at least 7 days, and
&& &
&
cents (37%) [1 ]. HMB is a condition with signifi- pad/tampon use should average 3–6/day [5 ,6 ].
cant impacts on adolescent quality of life due to HMB is defined as bleeding more than 7 days or
&

school absenteeism and limitations to sports or
&
social activity participation [2 ,3,4]. In one survey,
almost 60% of adolescents reported that HMB had
&
a serious effect on life activities [2 ]. It is vital
that providers accurately recognize, evaluate, and
more than 80 ml of blood loss/menstrual cycle [6 ].
Some additional signs of HMB include changing a
pad or tampon less than 1–2 h, use of double hy-
giene protection, frequent soiling of clothes or bed
sheets, blood clots more than 1 inch diameter, or
&

treat abnormal uterine bleeding (AUB) and HMB affects quality of life [6 ].
in adolescents.

NORMAL MENSES Baylor College of Medicine, Houston, Texas, USA

The average age of menarche is 12–13 years, with
the first menstrual period typically occurring 2–3
&&
years after thelarche [5 ]. Menses should occur
every 21–45 days, and although there is some irreg-
ularity in the first several years after menarche,
Correspondence to Jennifer E. Dietrich, MD, MSc, Baylor College of
Medicine, 6651 Main St, Suite 1020, Houston, TX 77030, USA.
Tel: +1 832 826 7464; e-mail: jedietri@bcm.edu
Curr Opin Obstet Gynecol 2017, 29:000–000
DOI:10.1097/GCO.0000000000000394

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Adolescent and pediatric gynecology
KEY POINTS
 Anticipatory guidance regarding puberty and normal
menstrual patterns should be given to patients and their
families starting around age 7–8, and providers should
ask for the last menstrual period and document
menstrual patterns at every visit after menarche.
 The most common causes of HMB in adolescents are
nonstructural, and include anovulatory bleeding from
immature HPO axis or PCOS and bleeding disorders
such as vWD and platelet function disorders.
 Utilizing a standard protocol for evaluation of
adolescents presenting with HMB can improve time to
diagnosis and management.
 Multidisciplinary clinics can provide complete
evaluation and collaborative management plans for
adolescents with bleeding disorders.
 Many hormonal and nonhormonal therapy options are
available for the management of HMB; surgical
management in the adolescent population is reserved
for life threatening situations or as a last resort when
medical management fails.
CHALLENGES TO DIAGNOSIS IN THE
ADOLESCENT POPULATION
HMB in adolescents is a challenging but often over-
looked problem, and there is frequently a delay in
diagnosis. It is often difficult to obtain an accurate
menstrual history from adolescents because of many
factors: inconsistency with disclosure, recall difficul-
ty, variety in feminine hygiene product use, and
cycle-to-cycle variability, so information obtained
regarding one period is not generalizable [7].
Additionally, children may have an undiagnosed
bleeding disorder because of lack of hemostatic
Table 1. International Federation of Gynecology and Obstetrics classification system for causes of abnormal uterine bleeding
in nongravid women of reproductive age, using the acronym PALM-COEIN
PALM: Polyp AUB
Structural causes
Adenomyosis AUB
Leiomyoma AUB-L
Malignancy and hyperplasia AUB
COEIN: Coagulopathy AUB
Nonstructural causes
Ovulatory dysfunction AUB
Endometrial AUB
Iatrogenic AUB
Not yet classified AUB
AUB, abnormal uterine bleeding.
Adapted with permission [10].
2 www.co-obgyn.com
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&
challenges until menarche [8 ]. For these reasons,
it is recommended that providers give anticipatory
guidance to patients and families prepubertally
&&
[5 ]. Providers should treat menses as a vital sign,
documenting last menstrual period and menstrual
patterns each visit in an effort to identify abnormal
&&
menses earlier [5 ]. Physicians should ask patients
to track cycles, using a chart or electronic applica-
&& &
tion for improved recall [5 ,9 ].
DIFFERENTIAL DIAGNOSIS
Once it has been determined that an adolescent has
HMB, it is crucial to complete a thorough work up
for underlying causes. Providers should refer to
the International Federation of Gynecology and
Obstetrics classification system for AUB/HMB
(Table 1) [10]. As opposed to adult women, the most
common causes of HMB in adolescents are non-
structural, with anovulatory bleeding and bleeding
&
disorders being most common [1 ]. Anovulation in
adolescents may be because of the immature HPO
axis from recent menarche; however, this is a diag-
nosis of exclusion. Polycystic ovary syndrome
(PCOS) is another common cause of anovulatory
bleeding, and is frequently underrecognized in ado-
lescents; the percentage of PCOS causing severe
&
AUB has also increased in recent years [11 ]. Bleed-
ing disorders are rare in the general population [von
&
Willebrand disease (vWD) prevalence is 1% [1 ]],
however in patients with HMB the incidence of
bleeding disorders is disproportionately increased,
with up to 30% of adolescents found to have a
&
bleeding disorder (Table 2) [12 ,13]. Other causes
of HMB include thyroid disease, pregnancy, sexual-
ly transmitted infections, and medications (Table 3)
& & &
[6 ,11 ,14 ].
Submucosal (AUB-LSM)
Other (AUB-LO)
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GCO 290504

Heavy menstrual bleeding in adolescents Moon et al.

Table 2. Red flags of bleeding disorders Table 3. Differential diagnosis of heavy menstrual
bleeding in adolescents
Red flags of bleeding disorders
Endocrine
Prolonged bleeding from trivial wounds lasting >15 min Anovulatory bleeding
Heavy, prolonged, or recurrent bleeding after surgery Polycystic ovary syndrome
Heavy, prolonged, or recurrent bleeding after dental procedures or Thyroid disease
tooth extraction
Bleeding disorders
Bruising with minimal or no trauma, especially resulting in a lump
von Willebrand disease
1–2 times/month
Platelet dysfunction
Nose bleeds lasting >10 min or requiring medical attention 1–2
times/month Thrombocytopenia
Unexplained bleeding from the gastrointestinal tract Clotting factor deficiency
Anemia requiring iron therapy or transfusions Infection
Heavy menstrual bleeding Sexually transmitted infections
Family history of bleeding disorders such as von Willebrand disease Cervicitis
or hemophilia Endometritis
Family history of hysterectomy at a young age Pregnancy
Postpartum hemorrhage Abortion
&
Ectopic pregnancy
Adapted with permission [6 ].
First trimester bleeding
Gestational trophoblastic disease
Postpartum bleeding
EVALUATION Medication
HMB may be either acute or chronic, therefore Anticoagulants
patients may present in the clinic or emergency Depot medroxyprogesterone
setting. A focused history and physical exam will Intrauterine Device
help to guide the differential diagnosis and work up
&& Uterine
(Tables 4 and 5) [15 ]. It can be useful to have
Leiomyoma
patients fill out screening surveys or bleeding
Polyp
charts to aid the history; however, these have most-
ly been studied in the adult population. In one Aenomyosis
study, the Pictorial Blood Assessment Chart was Malignancy
shown to be effective in adolescents as well, using Other
the same cutoff score (>100) to determine HMB Trauma
that warrants further work up [7]. Another fre- Foreign body
quently used screening tool is the International Hemorrhagic ovarian cysts
Society on Thrombosis and Hemostasis Bleeding
& &
Assessment Tool [8 ].
&
Adapted with permission [6 ,11 ].

One particular challenge in the evaluation and

management of adolescent HMB is that there may
be incomplete or inconsistent evaluation, and wide
variations in management. One recent study found
that among adolescents who had presented emer-
gently with AUB, only 52% of patients had age of
All adolescents presenting with HMB should
have an initial evaluation that includes screening
for bleeding disorders, anemia, iron deficiency, thy-
roid abnormalities, and pregnancy (Table 6) [18 ].
&&

menarche recorded, and only 45% of providers
asked about symptoms that would suggest a bleed-
&
ing disorder [16 ]. In the same study, only 23% of
patients had laboratory evaluation for a bleeding
&
disorder [16 ]. It has been demonstrated that a mul-
tidisciplinary clinic utilizing a standard protocol for
work up of adolescents with HMB improves time to
diagnosis. In one study, a historical cohort of wom-
en with type 1 vWD had an average time to diagno-
sis of 16 years, whereas the study’s multidisciplinary
&&
clinic average was only 4 months [17 ].
First tier bleeding disorder work up includes a von
Willebrand panel, coagulation tests, and platelet
aggregation studies; recent studies have shown that
platelet function disorders are the second most
common bleeding disorder in adolescents, and
screening for these should also be included
& &&
[1 ,18 ,19]. It is important to note several factors
can affect bleeding disorder testing. Acute bleeding
episodes, stress, and high doses of estrogen (>50 mg)
can affect von Willebrand factor; recent NSAID use
and selective serotonin reuptake inhibitors can

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Adolescent and pediatric gynecology
Table 4. Focused history for evaluation of heavy menstrual
bleeding in adolescents
Menstrual history and bleeding pattern
Age of menarche, regularity of menstrual cycle, quantity of
bleeding, frequency of changing pads or tampons, presence of
clots, soiling of clothes or bed sheets, impact on quality of life
Symptoms of anemia
Headache, palpitations, shortness of breath, dizziness, fatigue,
pica
Sexual and reproductive history
Use of contraception, history of sexually transmitted infections,
pregnancy history and outcomes, possibility of current pregnancy
Associated symptoms
Fever, chills, increasing abdominal girth, pelvic pressure or pain,
bowel or bladder dysfunction, vaginal discharge or odor
Symptoms associated with a systemic cause of abnormal uterine
bleeding/heavy menstrual bleeding
Obesity, CPOS, hypothyroidism, hyperprolactinemia,
hypothalamic, or adrenal disorder
Chronic medical illness
Interited bleeding disorders (coagulopathy, blood dyscrasias,
platelet function disorders), systemic lupus erythematosus,
connective tisssue diseases, liver disease, renal disease,
cardiovascular disease
Medications
Hormonal contraceptives, anticoagulants, selective serotonin
reuptake inhibitors, antipsychotics, tamoxifen, herbals (e.g.,
ginseng)
Family history
Coagulation or thromboembolic disorders, hormone-sensitive
cancers
& &&
Adapted with permission [6 ,15 ].
&&
affect platelet function testing [18 ]. Testing for
vWD can be performed while the patient is taking
combined oral contraceptives (COCs) as these typi-
&&
cally only contain 30–35 mg of estrogen [18 ]. VWD
testing and platelet function analysis should be
performed twice to confirm the results. Because iron
deficiency with or without anemia is common, first
tier testing should include either a ferritin level or an
& &
iron panel [20 ,21 ]. Additional testing during initial
evaluation may be obtained as indicated by history
and physical exam, such as sexually transmitted
infection screening and evaluation for PCOS
& &&
[11 ,18 ]. Routine ultrasound should not be
obtained solely for the work up of HMB in adoles-
cents, as the majority of causes are nonstructural. A
&
recent study by Pecchioli et al. [22 ] showed that
only two of 156 adolescent patients were found to
have a structural abnormality, and ultrasound find-
ings did not alter the management plan for any of
their patients.
If the first tier results are normal, or if the patient
fails initial management, then second tier testing
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Table 5. Focused physical examination for evaluation of
heavy menstrual bleeding in adolescents
Vital signs
Temperature, blood pressure, pulse, orthostatics (as clinically
indicated), height, weight, BMI
Neck
Thyroid examination
Abdomen
Tenderness, distension, striae, palpable masses, hepatomegaly
Skin
Pallor, bruising, petechiae, signs of hirsutism, acanthosis
nigricans, acne, scarring
External genitalia examination
Inspection of vulva, hymen and lower vagina, urethra, and anus
for abnormalities, source of bleeding, trauma, prolapse, signs of
cancer
Sexual maturity rating
Speculum examination (if clinically indicated)
Further examination of vagina and cervix
Digital or bimanual examination (if clinically indicated)
Examine uterus and adnexal structures for size, masses,
tenderness
Rectal examination (if clinically indicated)
If bleeding from the anus or rectum is suspected, or if risk of
concomitant pathology
& &&
Adapted with permission [6 ,15 ].
may be considered (Table 6). If not already obtained,
& &&
screening for PCOS is indicated [11 ,18 ]. Pelvic
ultrasound may be indicated if patients do not
&& &
respond to initial treatment [18 ,22 ]. Liver func-
&&
tion testing should be performed [18 ]. Additional
bleeding disorder work up for rarer conditions
should be undertaken by a hematologist, and may
include dysfibrinogenemia panel, fibrinolysis test-
ing, coagulation factor assays, and further platelet
&&
function testing [18 ].
MANAGEMENT
The goals of HMB treatment are to reduce morbidity,
restore and maintain normal blood volumes, pre-
vent life-threatening hemorrhage, and improve
quality of life [23]. There are many options effective
in managing acute HMB (Table 7). The patient
may be subsequently transitioned to a maintenance
therapy.
INTRAVENOUS FLUIDS AND BLOOD
PRODUCTS
A patient may receive intravenous (i.v.) crystalloid
or blood products in the acute management of
HMB if the patient demonstrates hemodynamic
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Heavy menstrual bleeding in adolescents Moon et al.

Table 6. First and second tier testing for evaluation of heavy menstrual bleeding in adolescents
First tier Pregnancy test
Hematologic tests:
CBC, reticulocyte count
Iron profile or ferritin level
Blood type and screen
Endocrine tests:
TSH, free T4
Bleeding disorder evaluation:
von Willebrand panel – von Willebrand factor antigen, factor VIII, ristocetin cofactor activity
Platelet function defects – platelet aggregation or PFA-100
Coagulation studies: PT/INR, aPTT, fibrinogen
Gynecologic tests (if indicated by patient history):
PCOS screening – FSH, LH, testosterone, DHEA-S
Sexually transmitted infection screening – Chlamydia trachomatis, Neisseria gonorrhoeae
Second tier Bleeding disorder evaluation (in consultation with hematologist):
Repeat von Willebrand disease testing (regardless of initial results), multimer analysis
Repeat platelet aggregation (if initial results are abnormal)
Dysfibrinogenimia panel – thrombin time, fibrinogen antigen, reptilase time (if thrombin time or fibrinogen abnormal)
Coagulant factor assays – Factor XI, Factor IX, Factor VII, Factor XIII
Fibrinolysis testing – euglobulin clot lysis time, a-2 antiplasmin, plasminogen activator-1 activity
Platelet glycoprotein expression/flowcytometry (based on platelet aggregation testing)
Electron microscopy – platelet granules (based on platelet aggregation testing)
Gynecologic tests:
Pelvic ultrasound – if not responding to medical therapy
PCOS screening – if not already performed
Liver function tests:
ALT, bilirubin (if prolonged PT)

aPTT, partial thromboplastin time; CBC, complete blood count; DHEA-S, dihydroepiandrosteindione sulfate; FSH, follicle stimulating hormone; INR, international
normalized ratio; LH, luteininzing hormone; PCOS, polycystic ovary syndrome; PFA, platelet function analyser; PT, prothrombin; T4, thyroxine; TSH, thyroid
stimulating hormones.
& && &&
Adapted with permission [6 ,17 ,18 ].

instability and severe anemia [23]. The need for
platelets is rare for AUB, however, may be necessary
in cases of severe thrombocytopenia (<50 000) or
&
platelet disorder [24 ]. Adolescents with clotting
factor deficiencies may require clotting factor
replacement with plasma-derived concentrate or
&
recombinant agents [12 ].
ESTROGEN
In the acute setting of HMB, i.v. conjugated equine
estrogen (CEE) should be considered [25]. For acute
HMB, i.v. CEE can be administered in 25 mg doses
every 4–6 h in patients who are hemodynamically
unstable or are unable to tolerate oral therapy
& &&
[6 ,15 ]. i.v. CEE is routinely continued for at least
24 h or until cessation of bleeding, followed by
&
transition to maintenance therapy [6 ].
COMBINATION ESTROGEN-
PROGESTERONE METHODS
Combination estrogen and progesterone methods
include the COC pill, transdermal patch, and vagi-
nal ring. In the treatment of HMB, dienogest/estra-
diol valerate is the only COC pill that has been
granted approval by the US Food and Drug Admin-
istration; it effectively reduced menstrual blood loss
(MBL) when compared to placebo in a randomized
&&
controlled trial [15 ]. Currently, there is not
enough data to suggest that one type of combined
method is superior to another. Nondaily combined
methods such as the patch (weekly) or the vaginal
ring (monthly) may improve compliance among
adolescents and should be offered as an option
&&
[18 ]. Combined methods can also be used to ex-
tend the interval of menstrual bleeding to a 12-week
cycle, or they can be taken in a continuous fashion

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Adolescent and pediatric gynecology

Table 7. Medical management of heavy menstrual bleeding

Conjugated Combined oral Depot medroxyprogester-
equine estrogen contraceptives Progesterone-only pills one acetate

Regimen Regimens Regimens Regimens

25 mg i.v. every 50 mg ethinyl estradiol combined pill PO every 6– Medroxyprogesterone 150 mg IM injection every
4–6 h  24 h 8 h for 1 week then taper down every week to daily acetate PO 10–20 mg 12 weeks
Contraindications dosing every 6–8 h for 1 week 104 mg SQ every 12
Pregnancy 30–35 mg ethinyl estradiol combined monophasic then taper down every weeks
Venous or arterial pill PO every 6–8 h for 1 week then taper down week to daily dosing Can be given in
thromboembolic every week to daily dosing Norethindrone acetate PO combination with an oral
disease (active or Contraindications 5–10 mg PO every 6–8 h progesterone-only pill
previous) Pregnancy for 1 week then taper regimen for acute heavy
Breast cancer Breast cancer (current or past) down to daily dosing menstrual bleeding
Obesity (use with Venous thrombosis or arterial thromboembolic Contraindications Contraindications
caution) disease (active or previous) Pregnancy Pregnancy
Side-effects Known thrombogenic mutations Breast cancer (current or Breast cancer (current or
Nausea/vomiting Hypertension (>160/100 mmHg) past) past)
Spotting or SLE with valvular disease, nephritis, or APL Liver dysfunction or Liver dysfunction or
breakthrough antibodies disease disease
bleeding Headaches with aura Side-effects Multiple risk factors for
Headache Liver dysfunction or disease Irregular bleeding cardiovascular disease
Breast pain Risk factors for cardiovascular disease Amenorrhea Hypertension with vascular
VTEs Stroke Contraception disease
Stroke Major surgery with prolonged immobilization No Side-effects
IM Side-effects Decreased bone mineral
Contraception Nausea/vomiting density
No Spotting or breakthrough bleeding Irregular bleeding
Headache Amenorrhea
Breast pain Weight gain
VTEs Breast pain
Stroke Fluid retention
IM Yes
Contraception
Yes

Levonorgestrel intrauterine GnRH agonist (leuprolide

device acetate) Tranexamic acid Others

Regimen Regimens Regimens NSAIDs

Intrauterine placement every 5 3.75 mg IM every month 10 mg/kg i.v. every 6–8 h for 2– Regimen: Ibuprofen 600–800 mg
years 11.25 mg IM every 3 months 8 days every 6–8 h (best if used with
Releases 20 mg/day Can be used with add-back 1300 mg PO every 8 h for 5 days other medication)
Used for long-term management therapy to prevent side-effects Contraindications Should be avoided in patients
Contraindications Norethindrone acetate 5 mg PO Thromboembolic disease (current with suspected bleeding disorders
Pregnancy every day or past) Contraindications: pregnancy, GI
Breast cancer (current or past) Contraindications Acquired impaired color vision bleeding, IBD, severe asthma,
Liver dysfunction or disease Pregnancy Can increase thrombosis risk CKD, CVD, CHF
Sexually transmitted disease Side-effects when combined with estrogen or Side-effects: GI adverse effects
within 3 months Hot flashes progesterone therapy (bleeding, ulceration,
Pelvic inflammatory disease Sweating Side-effects perforation), worsening asthma,
Untreated cervical or uterine Vaginal dryness Headaches platelet dysfunction
cancer Trabecular bone loss with use for Nausea/vomiting Contraception: No
Unexplained abnormal uterine longer than 6 months Diarrhea Aminocaproic acid
bleeding Contraception Muscular pain 100–200 mg/kg (maximum
Large or distorted uterine cavity No Dysmenorrhea 30 g/d) i.v. or PO every 4–6 h
(should be 6–10 cm) Contraception until bleeding controlled
Side-effects No Available in oral solution
Irregular bleeding or spotting 1-deamino-8-D-arginine vasopressin
Cramping Reserved for cases when all
Breast pain hormonal and nonhormonal
Acne therapies have failed
Nausea Collaboration with a hematologist
Contraception is strongly recommended before
Yes initiation

APL, antiphospholipid; CHF, congestive heart failure; CKD, chronic kidney disease; CVD, cardiovascular disease; GI, gastrointestinal; IBD, inflammatory bowel
disease; IM, intramuscular; i.v., intravenous; SLE, systemic lupus erythematosus; SQ, subcutaneous; VTE, venous thromboembolism.
& &&
Adapted with permission [6 ,15 ].

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GCO 290504
indefinitely. Although these extended cycle regi-
mens carry a risk of breakthrough bleeding, they
still decrease the overall MBL because of fewer bleed-
ing episodes when compared with monthly cycles
&&
[15 ]. When transitioning off of i.v. CEE to a COC
pill, various tapering regimens are available (Table 7)
& &&
[6 ]. Although on a tapering regimen, it is important
to discard the placebo pills. If an adolescent already
on a combined method presents with acute HMB,
initiating i.v. CEE or a high-dose COC taper is
recommended.
PROGESTERONE-ONLY OPTIONS
Patients with contraindications to estrogen (Table 7)
should be offered progesterone-only options. Two
commonly used oral progestin therapies in the ado-
lescent population include medroxyprogesterone
acetate (MPA) and norethindrone acetate. In the
acute setting, these can be prescribed as a taper
(Table 7) or they can be used daily once on mainte-
nance therapy. Strict compliance is required to pre-
&&
vent breakthrough bleeding [18 ].
Depot medroxyprogesterone acetate (DMPA) is
another option which can be administered as an
intramuscular (IM) or subcutaneous injection. A
recent systematic review concluded that these
two formulations appear to be therapeutically
&
equivalent and have similar side-effects [26 ]. The
subcutaneous route is commonly used in patients
with bleeding disorders to prevent hematoma
formation. DMPA can result in amenorrhea in up
to 50% of patients and is typically given every
&
12 weeks [27 ]. The injection interval can be
reduced to every 4, 8, or 10 weeks to prevent or
decrease heavy breakthrough bleeding; once the
bleeding has resolved the interval can be extended
to 12 weeks. DMPA is most commonly used as
maintenance therapy. A recent pilot study in
adults showed a cessation of acute bleeding in
2.6 days after administration of DMPA 150 mg IM
combined with 3 days of MPA 20 mg every 8 h [28].
More studies are needed on the utility of DMPA
for the treatment of acute and chronic AUB in
adolescents.
Long-term maintenance options include the
etonorgestrel subdermal implant and the levonor-
gestrel-releasing intrauterine device (LNG-IUD).
The etonorgestrel implant is a highly effective con-
traceptive option that lasts for 3 years but it has
not been well studied in the treatment for HMB
&
[27 ]. Although it can result in amenorrhea in up
to 24% of patients, the most common side-effect
is irregular bleeding which is also the most
common reason for discontinuation [29]. The
LNG-IUD is a device that is placed in the uterine
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Heavy menstrual bleeding in adolescents Moon et al.
cavity and lasts for 5 years; LNG-IUDs with lower
doses have not been studied for treatment of
HMB. Many studies have demonstrated the superi-
ority of the LNG-IUD over oral MPA, norethindrone
acetate, DMPA, and COCs, as there is greater
reduction in HMB and improved quality of life
[15 ,30]. LNG-IUD is also effective in improving
HMB and anemia in adolescents with bleeding dis-
&
orders [31 ]. The quality of life and reduction in
MBL was not significantly different between the
LNG-IUD and surgical management with endome-
trial ablation or hysterectomy in adult women
& &
[32 ,33 ].
GONADOTROPIN-RELEASING HORMONE
AGONISTS
Gonadotropin-releasing hormone agonists such
as depoleuprolide can be used in severe cases of
chronic HMB (hematologic or oncologic-related
cases), but is not reliable for use in acute HMB.
Within 3–4 weeks of administration, gonadotropin-
releasing hormone agonists result in endometrial
&&
atrophy and amenorrhea [15 ]. In addition to mood
changes and vasomotor symptoms, loss of bone
mineral density can occur with more than 6 months
&
of use [34 ]. To prevent these side-effects, add-back
&
hormonal therapy is recommended [34 ].
NONHORMONAL OPTIONS
NSAIDs have been shown to decrease HMB in pre-
menopausal women; however, they are not as
effective as other medical therapies [35]. Patients
with suspected bleeding disorders should avoid
&&
NSAIDs as they can exacerbate HMB [18 ]. Tranexa-
mic acid is an antifibrinolytic agent; multiple stud-
ies in adult women have shown a significant
reduction of HMB with tranexamic acid when com-
&&
pared to placebo [15 ]. Oral tranexamic acid is as
efficacious as COC pills in reducing MBL and
improving quality of life in adolescents with HMB
[36]. Tranexamic acid is therefore an effective op-
tion in the treatment of HMB in the adolescent
&
population [6 ]. Aminocaproic acid is another
antifibrinolytic agent that can be used in HMB;
however, it is less potent and has more side-
effects [37]. Other hematologic medications such as
1-deamino-8-D-arginine vasopressin or factor
replacement may be indicated for patients with
specific bleeding disorders. Although 1-deamino-
8-D-arginine vasopressin is used in patients with
type I vWD, hemophilia A, and in women with a
prolonged bleeding time without a bleeding disor-
der, it is best to consult with a hematologist prior to
& &
administration [12 ,26 ].
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GCO 290504
Adolescent and pediatric gynecology
SURGICAL MANAGEMENT
When medical therapy fails or in the event of a life-
threatening emergency, surgical management for
HMB in adolescents can be considered. Fertility
preservation should be a priority when considering
surgical measures or invasive procedures. One
option is uterine balloon tamponade (Bard, Coving-
ton, GA). Studies on intrauterine balloons have
mostly involved women with postpartum hemor-
rhage; however, these studies have demonstrated an
effective reduction in bleeding when needed emer-
&
gently [6 ]. In the adolescent population, a 30cc
Foley balloon (Bard, Covington, GA) is typically
used to accommodate a smaller uterus for tampo-
&
nade [6 ]. In older women, dilation and curettage
has not been effective in treating HMB and is also
not recommended for treatment for HMB manage-
&&
ment, especially in adolescents [18 ]. Endometrial
ablation destroys the endometrium through various
methods, and studies have shown that endometrial
ablation successfully reduces HMB in postmeno-
pausal women; however, this is not a recommended
strategy in adolescents because of fertility affects
and because of high failure rates in young women
&
[27 ]. Last, a hysterectomy is a major surgical pro-
cedure, which removes the uterus and resolves
HMB. To maintain fertility in the adolescent, sur-
gery should be avoided unless absolutely necessary
&
in life-threatening circumstances [6 ].
MULTIDISCIPLINARY APPROACH
Young women with bleeding disorders may be inade-
quately treated at the time of menarche despite hav-
ing a diagnosis. A retrospective review of adolescents
with bleeding disorders showed that the majority of
prepubertal girls did not discuss with their provider
any treatment plans, including whether they needed
more than one medication to control HMB following
&&
menarche [38 ]. To prevent HMB complications,
adolescents with bleeding disorders should be man-
aged in a multidisciplinary setting in consultation
with a pediatric gynecologist and hematologist before
they reach menarche; this collaboration should also
&&
be continued beyond menarche [38 ]. Consultation
with a hematologist at the time of initial presentation
in a patient with HMB and potentially unknown
bleeding disorder is important, particularly for diffi-
cult cases which are unresponsive to medical therapy
& anticipatory guidance about normal menses and what to expect with menarche
[6 ]. To improve clinical outcomes, a multidisciplin-
&&
ary approach is recommended [17 ].
TRANSITION TO ADULTHOOD
Young adults with bleeding disorders or chronic
medical conditions face unique challenges in their
8 www.co-obgyn.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
transition from adolescence to adulthood including
establishing a career, becoming independent from
their parents, and switching to an adult medical
clinic [39]. Numerous studies have shown that
adherence to treatment decreases in late childhood
&
and adolescence [40 ]. Motivational techniques
implemented by parents and caregivers can improve
&
adherence and self-care in adolescents [40 ].
CONCLUSION
HMB is common in adolescents. It is important to
have strategies for early identification of HMB
causes to offer the best treatments. First-line treat-
ments focus on medical management, both hor-
monal and nonhormonal options, rather than
invasive interventions as maintenance of fertility
is critical in this age group.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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