What is the best treatment approach for a 13-year-old female with menorrhagia?

Treatment of Menorrhagia in a 13-Year-Old Female

For a 13-year-old with menorrhagia, start with tranexamic acid 1.5-2g three times daily during menstruation as first-line therapy, while simultaneously screening for bleeding disorders (particularly von Willebrand disease) and iron deficiency anemia. 1, 2, 3

Initial Diagnostic Evaluation

Mandatory Laboratory Testing

• Screen for iron deficiency anemia immediately, as menorrhagia is the most common cause of iron deficiency in women of reproductive age, affecting 20-25% of this population 1, 2
• Test for bleeding disorders, particularly von Willebrand disease (VWD), which is the most common inherited bleeding disorder in women and causes menorrhagia in 32-100% of affected patients 3
• Perform laboratory testing during menstrual bleeding to capture the lowest levels of VWF:Ag and FVIII:C 3
• Rule out thyroid disorders, pregnancy (if sexually active), and sexually transmitted infections 4

Physical Examination Priorities

• Conduct pelvic examination to assess for uterine pathology (fibroids, polyps) 2
• Evaluate for signs of bleeding disorders (bruising, petechiae) 3

First-Line Medical Treatment Algorithm

Primary Non-Hormonal Option (Preferred for Adolescents)

• Tranexamic acid 1.5-2g three times daily during menstruation reduces menstrual blood loss by 34-59% over 2-3 cycles 1, 2
• This is particularly effective if bleeding disorders are present or suspected 1, 3
• Alternative: NSAIDs (mefenamic acid 500mg three times daily or ibuprofen) for 5-7 days during bleeding episodes 5, 4, 6

Hormonal Options (If Non-Hormonal Fails or Contraception Desired)

• Combined oral contraceptives are effective for regularizing cycles and reducing bleeding 1, 2
• These provide contraception benefit if sexually active and are more appropriate than LNG-IUS in this age group 1
• Avoid levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line in a 13-year-old, despite being most effective overall, due to insertion challenges and patient preference in this age group 1, 7

If Severe Thrombocytopenia Present

• Oral progestins (norethindrone) may be useful 2, 4
• Do not use progestins for more than 6 months due to meningioma risk 1, 2
• Avoid DMPA due to irregular bleeding and 11-13 week irreversibility 2, 4

Anemia Management Protocol

Iron Supplementation

• Ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1, 2
• Consider adding ascorbic acid to improve iron absorption 2
• Continue treatment for three months after correction of anemia to replenish iron stores 1, 2

Monitoring Schedule

• Monitor hemoglobin and MCV every 3 months for 1 year, then annually 1, 2
• Re-evaluate at 3-6 months after initiating treatment to assess efficacy 1, 2

Special Considerations for Adolescents

Bleeding Disorder Workup

• VWD prevalence in adolescents with menorrhagia ranges from 32-100% 3
• A detailed menstrual history combined with PBAC score >100 increases screening sensitivity to 95% 3
• If VWD confirmed, treatment options include: tranexamic acid, desmopressin (DDAVP), or factor VIII/VWF concentrates 3

Counseling Requirements

• Provide thorough counseling about expected bleeding patterns with any hormonal treatment to prevent non-adherence 4
• Discuss that unscheduled spotting or light bleeding is common with hormonal methods 5
• Reassure that amenorrhea with hormonal methods is not harmful 5

Common Pitfalls to Avoid

• Do not skip bleeding disorder screening in adolescents, as inherited coagulopathies are significantly more common in this population with menorrhagia 3
• Do not prescribe continuous progestins without time limits—avoid use beyond 6 months due to meningioma risk 1, 2
• Do not fail to address iron deficiency, as this significantly impacts quality of life and development in adolescents 1, 2
• Do not use DMPA in adolescents with menorrhagia due to paradoxical irregular bleeding and prolonged irreversibility 2, 4