What is the best course of treatment for a 16-year-old female experiencing menorrhagia (heavy menstrual bleeding) every 2 weeks and alopecia (hair loss), potentially due to polycystic ovary syndrome (PCOS)?

Management of Heavy Menstrual Bleeding Every 2 Weeks with Hair Loss in a 16-Year-Old Female

This adolescent requires immediate evaluation for an underlying bleeding disorder and anemia, followed by hormonal therapy with combined oral contraceptives as first-line treatment for both menstrual regulation and androgen suppression.

Initial Diagnostic Workup

The presentation of frequent heavy bleeding (every 2 weeks) combined with hair loss in an adolescent strongly suggests either a bleeding disorder, PCOS with anovulation, or both conditions coexisting.

Mandatory Laboratory Assessment

• Complete blood count with serum ferritin to assess for anemia from blood loss 1
• Hemodynamic stability assessment including orthostatic blood pressure and pulse measurements 1
• Bleeding disorder screening is critical, as 5-32% of adolescents with heavy menstrual bleeding have an underlying coagulopathy, most commonly von Willebrand disease (prevalence 32-100% in affected women) 1, 2
• Endocrine evaluation including testosterone, DHEA-S, and 17-hydroxyprogesterone to evaluate for PCOS and rule out other hyperandrogenic disorders 3, 4
• Pregnancy test is mandatory in all reproductive-age individuals with abnormal bleeding 5

Clinical Context

The combination of menstrual irregularity (bleeding every 2 weeks) and alopecia is highly suggestive of PCOS, which affects 5-20% of reproductive-age women and is characterized by hyperandrogenism, ovulatory dysfunction, and metabolic dysfunction 6. However, the frequency and severity of bleeding warrants bleeding disorder evaluation first 1.

First-Line Treatment: Combined Hormonal Contraceptives

Combined oral contraceptives (COCs) are the optimal first-line therapy for this patient as they address both the menstrual irregularity and the androgenic hair loss 7, 3, 4.

Specific Regimen

• Standard 24/4 formulation (24 active hormone pills followed by 4 placebo days) 8
• Initiate on the first Sunday after menstrual bleeding onset, with backup contraception for the first 7 days 8
• Counsel that withdrawal bleeding typically occurs within 3 days of completing active pills 8
• Breakthrough bleeding is common initially and usually transient without significance, but should prompt continued use rather than discontinuation 8

Mechanism of Benefit

• Suppresses ovarian androgen production, addressing the hair loss (alopecia) 3, 4
• Regulates menstrual cycles by creating predictable withdrawal bleeding 7
• Provides endometrial protection against hyperplasia from unopposed estrogen 5
• Improves dysmenorrhea if present 7

Alternative Hormonal Options

If COCs are contraindicated or not tolerated:

• Levonorgestrel IUD (20 μg/day) reduces menstrual blood loss by 71-95% and improves dysmenorrhea 5, 7
• Progestin-only options including oral progestins or injectable DMPA, though these may cause irregular bleeding patterns 9

Management of Acute Heavy Bleeding (If Present)

If the patient presents with acute heavy bleeding requiring immediate intervention:

Medical Management (First-Line)

• Tranexamic acid or aminocaproic acid (oral or IV) to stop acute bleeding 1
• NSAIDs for 5-7 days during bleeding episodes 9
• Short-term high-dose hormonal therapy: Low-dose COCs or estrogen for 10-20 days 9

Surgical Intervention

Reserved only for patients who:

• Do not respond to medical therapy
• Are clinically unstable despite initial measures
• Require examination under anesthesia for severe bleeding 1

Monitoring and Follow-Up

• Reassess at 3 months to evaluate bleeding pattern and treatment response 5
• Repeat hemoglobin and ferritin if anemia was present initially 1
• Evaluate hair regrowth at 3-6 months, as androgenic alopecia improvement takes time 3
• Screen for metabolic complications including glucose intolerance and lipid abnormalities if PCOS is confirmed 4, 6

Critical Pitfalls to Avoid

• Do not dismiss frequent heavy bleeding as "normal adolescent cycles" - this pattern warrants full evaluation for bleeding disorders 1, 2
• Do not delay bleeding disorder workup - laboratory testing should ideally be performed during menstrual bleeding to capture lowest VWF and Factor VIII levels 2
• Do not use antiandrogens without adequate contraception as they are teratogenic 3
• Do not expect immediate resolution - breakthrough bleeding typically resolves within 3 months of proper hormonal therapy 5
• Do not overlook lifestyle modification if obesity or insulin resistance is present, as this is first-line therapy for metabolic features of PCOS 4

Additional Considerations for PCOS Management

If PCOS is confirmed and metabolic dysfunction is present:

• Metformin may be added for insulin resistance, though it has minimal effect on hirsutism alone 3, 4
• Lifestyle modification (diet, exercise, behavioral strategies) should be recommended for patients with overweight, central obesity, or insulin resistance 4
• Long-term surveillance for type 2 diabetes, cardiovascular disease, and endometrial cancer is necessary 6