Management of Pubertal Menorrhagia
Pubertal menorrhagia should be treated with hormonal therapy, specifically progestins for mild to moderate cases and combined estrogen-progestin therapy for severe cases, with iron supplementation for all patients with anemia. 1
Definition and Epidemiology
- Pubertal menorrhagia refers to excessive menstrual bleeding during adolescence
- Occurs in approximately 10-30% of menstruating adolescents 2
- Most commonly begins within the first year after menarche (85% of cases) 1
Etiology Assessment
Primary Causes (In Order of Frequency)
Functional/Anovulatory bleeding (80-83% of cases) 1, 3
- Most common cause due to immature hypothalamic-pituitary-ovarian axis
- Results in unopposed estrogen stimulation of the endometrium
Bleeding disorders (10-15% of cases) 1, 3
- von Willebrand disease
- Idiopathic thrombocytopenic purpura
- Factor deficiencies
- Platelet function disorders
Endocrine disorders
- Hypothyroidism
- Polycystic ovary syndrome
Other medical conditions
- Renal or hepatic disease
- Malignancy (rare)
Diagnostic Approach
Initial Laboratory Evaluation
- Complete blood count with platelets
- Ferritin level (to assess iron stores)
- Coagulation studies (PT, PTT)
- Thyroid function tests
- Pregnancy test
Additional Testing Based on Clinical Suspicion
- von Willebrand factor antigen and activity
- Platelet function studies
- Hormonal evaluation (FSH, LH, estradiol) if irregular cycles
Severity Classification and Management
Mild Anemia (Hb > 11 g/dL)
First-line treatment: Oral progestins 1
- Medroxyprogesterone acetate 5-10 mg daily for 12-14 days every 28 days 4
- Norethisterone 5 mg daily for 12-14 days every 28 days
Iron supplementation for those with low ferritin 4
- Continue for three months after correction of anemia to replenish stores
Moderate Anemia (Hb 8-11 g/dL)
- First-line treatment: Oral progestins (as above) 1
- Iron supplementation (as above) 4
- Tranexamic acid for acute bleeding episodes
- Particularly useful in patients with suspected bleeding disorders
Severe Anemia (Hb < 8 g/dL)
First-line treatment: Combined estrogen-progestin therapy 1
- Followed by maintenance progestin therapy
- Consider hospitalization for severe cases
Blood transfusion if hemodynamically unstable or severe symptomatic anemia 3
Iron supplementation (as above) 4
- Parenteral iron if oral not tolerated, but only when absolutely necessary 4
Special Considerations
Patients with Known Bleeding Disorders
- Prophylactic hormonal therapy should be initiated before or at menarche 1
- Consider consultation with hematology
- Treatment options include: 5
- Tranexamic acid
- Desmopressin (for specific factor deficiencies)
- Clotting factor concentrates (if indicated)
- Hormonal therapy (as above)
Patients Undergoing Chemotherapy
- For cancer patients undergoing chemotherapy with thrombocytopenia: 4
- Continuous progestational agents preferred over combined oral contraception
- Medroxyprogesterone acetate preferred over norethisterone in patients with high risk of venous embolism
- Limit use to <6 months to prevent risk of meningioma
Follow-up and Monitoring
- Monitor hemoglobin and MCV at three-month intervals for one year, then annually 4
- Provide additional iron if hemoglobin or MCV falls below normal 4
- Long-term follow-up is essential as treatment may be required for several years 1
- High risk of recurrence, particularly in functional disorders 1
Important Clinical Pearls
- Severe menorrhagia most commonly occurs during the first three menstrual cycles 1
- Functional disorders account for 83% of cases but can still cause severe anemia requiring transfusion 1, 3
- Curettage is not indicated in the management of pubertal menorrhagia 1
- All patients with anemia should receive iron supplementation to correct anemia and replenish body stores 4
- Patients with severe menorrhagia should be evaluated for underlying bleeding disorders, even if the presentation suggests functional etiology 3, 5