What is the initial management and workup for a 14-year-old female presenting with heavy menstrual bleeding (Menorrhagia)?

From the Guidelines

The initial management of a 14-year-old female with heavy menstrual bleeding should focus on assessing hemodynamic stability, determining the severity of blood loss, and identifying underlying causes, with consideration of hormonal therapy as first-line treatment, as recommended by recent guidelines 1. The management approach should include a thorough history, physical examination, and laboratory tests to assess for anemia, coagulation disorders, and other underlying conditions.

• Key components of the initial assessment include:
  • Menstrual pattern and duration of symptoms
  • Associated symptoms such as pain or dysmenorrhea
  • Sexual activity and possibility of pregnancy
  • Vital signs to assess for tachycardia or hypotension
• Laboratory tests should include:
  • Complete blood count to assess for anemia
  • Coagulation studies (PT, PTT, INR)
  • Pregnancy test
  • Thyroid function tests
  • Possibly hormonal assays
• Hormonal therapy, typically with combined oral contraceptive pills (COCs) containing 30-35 mcg ethinyl estradiol, is the recommended first-line treatment for acute management of heavy menstrual bleeding in adolescents, as supported by guidelines 1.
• Non-hormonal options, such as tranexamic acid 1300 mg three times daily during menses, and iron supplementation (ferrous sulfate 325 mg daily) if anemia is present, should also be considered.
• NSAIDs like ibuprofen 600 mg every 6 hours can help reduce blood loss and manage pain.
• Adolescents with menorrhagia should be evaluated for underlying bleeding disorders, particularly von Willebrand disease, which affects up to 20% of adolescents with heavy menstrual bleeding, as noted in recent studies 1.
• Outpatient follow-up should be arranged within 2-4 weeks to assess treatment response and adjust management as needed.

From the FDA Drug Label

Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. Secondary amenorrhea, abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 2. 5 to 10 mg norethindrone acetate tablets may be given daily for 5 to 10 days to produce secretory transformation of an endometrium that has been adequately primed with either endogenous or exogenous estrogen.

The initial management and workup for a 14-year-old female presenting with heavy menstrual bleeding (Menorrhagia) is not directly addressed in the provided drug label. Key points to consider in the workup include:

• Ruling out organic pathology
• Evaluating hormonal imbalance
• Considering the patient's medical history and therapeutic response However, the provided label does not offer a clear workup plan for this specific condition and age group 2.

From the Research

Initial Management and Workup

The initial management and workup for a 14-year-old female presenting with heavy menstrual bleeding (Menorrhagia) involves several steps:

• Assessment of menstrual and gynaecological history to distinguish those who require additional haematological investigations 3
• Evaluation for anemia from blood loss, including serum ferritin, and the presence of an endocrine disorder leading to anovulation 4
• Physical examination to assess hemodynamic stability, including orthostatic blood pressure and pulse measurements 4
• Pelvic examination and ultrasound scan to rule out underlying pathology 3

Laboratory Assessment

Laboratory assessment is crucial in determining the underlying cause of heavy menstrual bleeding:

• Assessment for anemia and serum ferritin levels 4
• Evaluation for underlying bleeding disorder, such as von Willebrand disease 5
• Laboratory tests to rule out coagulopathy and ovulatory dysfunction 6

Treatment Options

Treatment options for heavy menstrual bleeding in adolescents include:

• Medical management, such as hormonal treatments (e.g., combined hormonal contraceptives, levonorgestrel-releasing intrauterine system) and hemostatic therapies (e.g., tranexamic acid, DDAVP) 3, 6, 4
• Nonmedical procedures, such as endometrial ablation, may be considered when there is a lack of response to medical therapy or when severe heavy bleeding warrants further investigation 3, 4
• Maintenance hormonal therapy, including combined hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices, may be used to reduce heavy menstrual bleeding 4

Multidisciplinary Approach

A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal:

• Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care 5
• Collaboration with hematologists and other specialists may be necessary to provide comprehensive care for adolescents with heavy menstrual bleeding and underlying bleeding disorders 4, 5