Management of Prolonged Menstrual Bleeding in a 17-Year-Old
For a 17-year-old with 3 months of continuous menstrual bleeding, immediately initiate combined oral contraceptives (COCs) at standard doses for 10-20 days to stop the bleeding, after ruling out pregnancy, sexually transmitted infections, and pathologic uterine conditions. 1, 2
Immediate Diagnostic Steps
Before starting any treatment, you must exclude:
- Pregnancy - Perform a urine pregnancy test immediately, as this is mandatory in all reproductive-age women with abnormal bleeding 1
- Sexually transmitted infections - Screen for STDs that can cause irregular bleeding patterns 1, 3
- Medication interactions - Ask about antibiotics, anticonvulsants, or other drugs that may affect hormonal balance 1, 3
- Pathologic uterine conditions - Consider imaging if bleeding persists after initial treatment to evaluate for polyps, fibroids, or endometrial abnormalities 1, 3
Critical point: Bleeding lasting more than 90 days is definitively abnormal in adolescents, even during the early gynecologic years, and requires evaluation and treatment. 4, 5
First-Line Treatment Protocol
Combined oral contraceptives for 10-20 days are the recommended first-line treatment for heavy or prolonged bleeding in adolescents: 1, 2
- Start immediately once pregnancy and infections are ruled out
- Use standard low-dose formulations (20-35 mcg ethinyl estradiol)
- Continue for 10-20 days to achieve hemostasis
- After the initial course, bleeding typically stops within 3-7 days 6
Alternative if COCs are contraindicated: Progestin-only therapy with norethindrone acetate 5-10 mg daily for 5-10 days can produce secretory transformation and stop bleeding, with withdrawal bleeding occurring 3-7 days after discontinuation. 6
Alternative Treatment Options
If combined hormonal contraceptives cannot be used due to contraindications (thromboembolism risk, cardiovascular disease, migraine with aura):
- NSAIDs (mefenamic acid 500 mg three times daily for 5 days OR celecoxib 200 mg daily for 5 days) can reduce bleeding but are less effective for prolonged bleeding of this duration 1, 2
- Progestin-only options including norethindrone acetate as described above 6
Long-Term Management After Acute Episode
Once the acute bleeding is controlled:
- Levonorgestrel-releasing IUD (52 mg) is the most effective long-term option, reducing menstrual blood loss by 71-95% and is safe and effective in adolescents 2, 7
- Continuous or extended-cycle COCs can prevent recurrent episodes of abnormal bleeding 8
- Planned menstrual cycling with progestins may benefit patients with recurrent episodes 6
Evaluation for Underlying Causes
While initiating treatment, investigate potential causes:
- Coagulopathy screening - Von Willebrand disease has high incidence in adolescents with heavy menstrual bleeding 7
- PCOS evaluation - Check LH/FSH ratio, testosterone, and glucose/insulin ratio if hyperandrogenism signs present 1
- Thyroid function and prolactin levels 1
- Complete blood count to assess for anemia requiring iron supplementation or transfusion 7
Critical Caveats
- Do not delay treatment - Three months of bleeding can cause significant anemia and reduced quality of life 7, 9
- Avoid aspirin - It may increase blood loss and is not effective for menstrual bleeding 2, 3
- Monitor for VTE risk - Combined hormonal contraceptives increase venous thromboembolism risk 3-4 fold, though this risk is still lower than pregnancy-related VTE risk 1
- Ensure follow-up - If bleeding persists despite treatment, consider alternative methods or subspecialty referral 1, 3
When to Refer
Refer to gynecology or hematology if:
- Bleeding does not respond to initial hormonal treatment within 7 days
- Severe anemia requiring transfusion is present 7
- Suspected bleeding disorder based on personal or family history 7
- Structural abnormalities are identified on imaging 1
A multidisciplinary approach involving gynecology and hematology is optimal for adolescents with suspected bleeding disorders. 7