What is the next step in managing a 14-year-old (yo) patient with menorrhagia (heavy menstrual bleeding) and easy bruising, with normal laboratory results?

From the Guidelines

The next step in managing a 14-year-old patient with menorrhagia and easy bruising, despite normal laboratory results, should be a trial of hormonal therapy, specifically combined oral contraceptive pills (COCPs). I would recommend starting with a monophasic COCP containing 30-35 mcg of ethinyl estradiol, such as Levora or Nordette, taken once daily for at least 3-6 months. This approach serves both diagnostic and therapeutic purposes, as suggested by recent studies 1. Hormonal therapy can effectively reduce menstrual bleeding by stabilizing the endometrial lining and regulating the menstrual cycle. If the patient responds well to hormonal therapy, this suggests the bleeding is likely due to anovulatory cycles common in adolescents with immature hypothalamic-pituitary-ovarian axis.

Some key points to consider in the management of this patient include:

• The use of hormonal therapy as a first-line treatment for menorrhagia in adolescents, as it can help regulate menstrual cycles and reduce bleeding symptoms 1
• The importance of counseling the patient on iron-rich foods and possibly starting iron supplementation if there are concerns about anemia developing from the heavy bleeding
• The need for further investigation for underlying bleeding disorders if symptoms persist despite hormonal therapy, including more specialized coagulation tests such as von Willebrand factor antigen, ristocetin cofactor activity, and factor VIII levels, as some mild bleeding disorders may not be detected on routine laboratory tests 1

It is also important to note that the management of menorrhagia and easy bruising in adolescents requires a comprehensive approach that takes into account the patient's overall health, medical history, and lifestyle. As such, a thorough evaluation and ongoing monitoring are necessary to ensure the best possible outcomes for the patient.

From the Research

Next Steps in Managing Menorrhagia and Easy Bruising

Given the patient's normal laboratory results, the next steps in managing a 14-year-old patient with menorrhagia (heavy menstrual bleeding) and easy bruising involve a comprehensive assessment to rule out underlying causes.

• A detailed menstrual and gynaecological history should be taken to assess the severity of menorrhagia, as outlined in 2.
• A bleeding score should be used to distinguish those who require additional haematological investigations, as suggested in 2 and 3.
• A pelvic examination and ultrasound scan can help rule out the presence of any underlying pathology, such as uterine fibroids, as mentioned in 2.
• The patient's history and physical examination findings should be evaluated to determine if there is a suspicion of a bleeding diathesis, as discussed in 4.
• If a bleeding disorder is suspected, the patient should be referred to a hematologist for laboratory evaluation and medical management, as recommended in 5.

Laboratory Evaluation

If the initial assessment suggests a bleeding disorder, laboratory testing may include:

• A complete blood count, peripheral blood smear, prothrombin time (PT), and partial thromboplastin time (PTT), as outlined in 4.
• Von Willebrand factor analysis, and if normal, platelet aggregation and release studies should follow, as suggested in 3.
• Further testing, such as a mixing study or vitamin K challenge, may be warranted based on the initial results, as discussed in 4.

Medical Management

Medical management of menorrhagia and easy bruising may involve:

• Hormonal treatments, such as combined hormonal contraceptives or levonorgestrel-releasing intrauterine system (LNG-IUS), as discussed in 2 and 5.
• Antifibrinolytics, such as tranexamic acid, to reduce menstrual blood loss, as mentioned in 2 and 5.
• Maintenance hormonal therapy, including combined hormonal contraceptives, oral and injectable progestins, and LNG-IUS, as outlined in 5.