What is the differential diagnosis and workup for a 10-year-old female with heavy menstrual bleeding for more than 1 month during her second period?

Heavy Menstrual Bleeding in a 10-Year-Old: Differential Diagnosis and Workup

In a 10-year-old with heavy menstrual bleeding during her second period, the primary concern is an underlying bleeding disorder, which affects approximately 20% of adolescents with heavy menstrual bleeding, and the workup must prioritize excluding coagulopathy before attributing symptoms to anovulation alone. 1

Differential Diagnosis

Most Likely Causes in This Age Group

Anovulatory bleeding is the most common etiology in adolescents due to immature hypothalamic-pituitary-ovarian axis, but this is a diagnosis of exclusion after ruling out bleeding disorders 2

Bleeding disorders (particularly von Willebrand disease) must be excluded, especially when heavy menstrual bleeding has been present since menarche 1, 2

Endocrine disorders including:

• Hypothyroidism 2
• Hyperprolactinemia 2
• Polycystic ovary syndrome (though less common at this age) 2

Key Clinical Predictors of Underlying Pathology

Heavy menstrual bleeding is highly suggestive of a bleeding disorder when accompanied by 3:

• Clots ≥1 inch diameter
• "Flooding" (changing pad/tampon more frequently than hourly)
• Personal or family history of bleeding symptoms
• Low ferritin levels

Comprehensive Workup

Initial Assessment

History must specifically document 1, 2:

• Menstrual pattern: duration, volume, presence of clots >1 inch
• "Flooding" episodes requiring pad/tampon changes more than hourly 3
• Personal bleeding history: easy bruising, epistaxis, gingival bleeding, prolonged bleeding from minor cuts
• Family history of bleeding disorders or heavy menstrual bleeding 1
• Medications, particularly anticoagulants 3

Physical examination should assess 1:

• Hemodynamic stability with orthostatic blood pressure and pulse measurements
• Signs of anemia (pallor, tachycardia)
• Thyroid examination
• Signs of hyperandrogenism (acne, hirsutism)
• Petechiae or bruising patterns

Laboratory Evaluation

Essential initial laboratory tests 1, 2:

• Complete blood count to assess for anemia
• Serum ferritin (critical marker of chronic blood loss) 1
• Thyroid-stimulating hormone (TSH) 4, 2
• Prolactin level 4, 2
• Pregnancy test (β-hCG) - must be excluded first 5

Bleeding disorder screening (mandatory in adolescents with heavy menstrual bleeding) 1, 2:

• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)
• von Willebrand factor antigen
• von Willebrand factor activity (ristocetin cofactor)
• Factor VIII level
• Platelet count and function studies if indicated

Hematology referral is indicated when bleeding disorder is suspected based on history, family history, or abnormal screening tests 1

Imaging Considerations

Pelvic imaging is generally NOT required in adolescents with heavy menstrual bleeding unless 4:

• Structural abnormality suspected on examination
• Medical management fails
• Atypical presentation warrants further investigation

Transvaginal ultrasound is contraindicated in this age group; transabdominal ultrasound would be the appropriate modality if imaging is needed 4, 5

Endometrial sampling is NOT indicated at age 10 unless there are specific high-risk features such as 5:

• Chronic anovulation with persistent unexplained bleeding
• Family history of Lynch syndrome
• Failed medical management

Critical Pitfalls to Avoid

Do not assume anovulation without excluding bleeding disorders - approximately 20% of adolescents with heavy menstrual bleeding have an underlying inherited bleeding disorder, and this percentage is higher when bleeding has been present since menarche 1, 2

Do not perform digital pelvic examination in this age group unless absolutely necessary for acute management 1

Do not delay hematologic evaluation if the patient has flooding, clots ≥1 inch, or personal/family bleeding history - these patients require coordination with hematology from the outset 3, 1

Do not overlook ferritin levels - this is the most sensitive marker for chronic blood loss and guides iron replacement therapy 1

Management Considerations After Diagnosis

Once the workup identifies the underlying cause, treatment strategy depends on 1, 2:

• Presence or absence of bleeding disorder
• Severity of anemia
• Hemodynamic stability
• Endocrine abnormalities identified

For acute heavy bleeding with hemodynamic instability 1:

• Medical management is first-line
• Antifibrinolytics (tranexamic acid or aminocaproic acid) in oral or IV form 1
• Combined hormonal contraceptives or high-dose progestins 1
• Surgery reserved only for those who fail medical therapy 1