What is the best approach to manage menorrhagia and dysmenorrhea in a 15-year-old patient?

Initial Evaluation of Heavy Periods and Cramping in a 15-Year-Old

Yes, you should perform bloodwork to assess for anemia and screen for bleeding disorders in this adolescent with heavy menstrual bleeding. 1, 2

Essential Laboratory Testing

Complete the following bloodwork:

• Complete blood count (CBC) to assess for anemia from blood loss 1
• Serum ferritin to evaluate iron stores (more sensitive than hemoglobin alone) 1
• Screening for bleeding disorders including von Willebrand disease, which has a high incidence in adolescents with heavy menstrual bleeding 2
• Thyroid-stimulating hormone (TSH) to exclude thyroid disease as a cause of anovulation 3

The prevalence of bleeding disorders is significantly higher in adolescent girls with heavy menstrual bleeding compared to the general population, with von Willebrand disease being the most common inherited bleeding disorder in this group 2. Anemia is frequently underdiagnosed in adolescents with menorrhagia, and some girls are unaware they have abnormal bleeding 4.

Physical Assessment Required

Perform these clinical assessments:

• Blood pressure and pulse (including orthostatic measurements if acute heavy bleeding) 1
• External genital examination (pelvic examination only if sexually active or clinically indicated) 3
• Assessment of hemodynamic stability 1

First-Line Medical Management

For dysmenorrhea (cramping):

• NSAIDs are first-line therapy (e.g., ibuprofen 400mg three times daily during menses) 3, 5, 6
• NSAIDs reduce prostaglandin production, which causes both pain and excessive bleeding 7, 6

For heavy menstrual bleeding:

• Combined hormonal contraceptives (pills, patch, or ring) are highly effective for both heavy bleeding and dysmenorrhea 3, 1
• Extended or continuous cycle regimens are particularly appropriate for adolescents with severe dysmenorrhea, anemia, or heavy bleeding 3
• Start with monophasic pills containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 3

For acute heavy bleeding:

• Tranexamic acid (antifibrinolytic) is effective for stopping acute bleeding 1
• High-dose hormonal therapy may be needed if bleeding is severe 3

Coordination with Hematology

If bleeding disorder is suspected based on:

• Positive family history of bleeding disorders
• Personal history of easy bruising, prolonged bleeding from minor cuts, or bleeding with dental procedures
• Abnormal screening laboratory results

Then coordinate care with a hematologist for comprehensive evaluation and management 1, 2

Common Pitfalls to Avoid

• Don't assume heavy periods are "normal" in adolescents – anovulation is common in the first 1-2 years post-menarche, but persistent heavy bleeding warrants evaluation 2
• Don't delay iron supplementation if anemia is present – ferrous sulfate 200mg three times daily should continue for 3 months after correction to replenish stores 3
• Don't overlook bleeding disorders – the incidence of von Willebrand disease is particularly high in this population 2
• Don't perform unnecessary pelvic examination – external examination is sufficient unless the patient is sexually active or has specific indications 3

Expected Outcomes

With prompt recognition and treatment, you can avoid transfusion, hospitalization, and significantly improve quality of life 2. The 52-mg levonorgestrel intrauterine device has superior efficacy for heavy menstrual bleeding and is safe in adolescents, though combined hormonal contraceptives remain first-line for most 2.