What is the management recommendation for a young girl experiencing menorrhagia (excessive menstrual bleeding) on her first day of menstruation?

From the Guidelines

For a young girl experiencing excessive bleeding on her first day of menstruation, immediate medical attention is recommended, with treatment options including NSAIDs for short-term treatment (5–7 days) or hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) 1. The most recent and highest quality study, although not directly related to the specific context of a young girl's first menstruation, provides guidance on managing heavy or prolonged bleeding, which can be applied to this scenario 1. Key considerations in management include:

• Assessing for underlying gynecological problems, such as interactions with other medications, STDs, pregnancy, or new pathologic uterine conditions, and treating or referring for care if identified 1
• Using NSAIDs or hormonal treatments for short-term management of bleeding, with the choice depending on the patient's medical eligibility and preferences 1
• Considering alternative contraceptive methods if heavy or prolonged bleeding persists and is unacceptable to the patient 1
• The use of tranexamic acid as a nonhormonal alternative to reduce bleeding symptoms, as supported by recent studies 1
• Ensuring hemodynamic stability and performing necessary laboratory tests, including complete blood count, coagulation studies, and pregnancy test, to guide treatment and further evaluation
• Providing follow-up care to monitor response to treatment and determine the need for further evaluation or alternative management strategies.

From the Research

Management of Excessive Menstrual Bleeding in Adolescents

• The first-line approach to acute bleeding in adolescents is medical management, with surgery reserved for those who do not respond to medical therapy 2.
• Antifibrinolytics such as tranexamic acid or aminocaproic acid in oral and intravenous form may be used to stop bleeding 2.
• Combined hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices can be used for maintenance hormonal therapy after correction of acute heavy menstrual bleeding 2, 3.
• The 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders 3.

Diagnosis and Evaluation

• 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 2.
• 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 2.
• Inherited and acquired bleeding disorders, such as von Willebrand disease, and quantitative and qualitative abnormalities of platelets are relatively common findings in adolescents with heavy menstrual bleeding from menarche 4.

Treatment Options

• Oral tranexamic acid and combined oral contraceptives have been shown to be equally effective in reducing mean blood loss among patients with heavy menstrual bleeding 5.
• The efficacy of both therapies was significantly higher in younger age groups, and patients with leiomyomas benefitted more significantly from combined oral contraceptives 5.
• Levonorgestrel-releasing intrauterine device is an effective tool for all adolescents with menstrual needs, including those with bleeding disorders 3, 4.