What is the treatment for puberty menorrhagia?

Treatment of Pubertal Menorrhagia

Combined oral contraceptives (COCs) are the first-line hormonal treatment for pubertal menorrhagia, with tranexamic acid serving as the preferred non-hormonal alternative. 1

First-Line Treatment Options

Combined Oral Contraceptives (COCs)

• COCs reduce menstrual blood loss by 40-50% through inducing regular shedding of a thinner endometrium and inhibiting ovulation. 1, 2
• They provide additional benefits including regulation of menstrual cycles, reduction of menorrhagia-associated anemia, and decreased formation of benign ovarian tumors. 1
• Avoid COC use within 2 years of menarche or in patients <14 years of age unless clinically warranted, due to concerns about bone mass development. 1

Tranexamic Acid (Non-Hormonal Option)

• This antifibrinolytic agent reduces menstrual blood loss by 20-60% and is the optimal choice for adolescents who cannot or prefer not to use hormonal therapy. 1
• Particularly useful when hormonal contraception is contraindicated or declined by the patient. 1

Second-Line Treatment Options

Oral Progestins

• Useful in specific populations such as those with severe thrombocytopenia, but should NOT be used for more than 6 months due to risk of meningioma development. 1
• In ovulatory women with menorrhagia, progestins achieve only a 20% reduction in blood loss, making them less effective than other options. 3
• More effective in anovulatory bleeding patterns common in early puberty. 4, 3

Levonorgestrel Intrauterine Device (LNG-IUD)

• Requires careful consideration of sexual activity status and patient preference in adolescents. 1
• May be appropriate for select patients but not typically first-line in this age group. 1

Treatment Algorithm Based on Severity

Mild Anemia (Hemoglobin >11 g/dL)

• Start with COCs (if age-appropriate) or tranexamic acid. 1, 4
• Progestins can be considered as alternative. 4

Moderate Anemia (Hemoglobin 8-11 g/dL)

• COCs or tranexamic acid remain first-line. 1, 4
• Consider progestins if hormonal contraception preferred but COCs contraindicated. 4

Severe Anemia (Hemoglobin <8 g/dL)

• Initiate estrogen-progestin therapy followed by progestin maintenance. 4
• These cases typically occur during the first three menstrual periods and are usually functional in origin. 4
• Blood transfusion may be required in severe cases. 5
• Treatment should continue for several years due to high risk of recurrence. 4

Critical Evaluation Steps

Rule Out Underlying Disorders

• Screen for bleeding disorders (von Willebrand disease, thrombocytopenia, factor deficiencies) especially if severe bleeding occurs early after menarche. 4, 5
• Check thyroid function (TSH) as hypothyroidism can cause menorrhagia. 5, 6
• Obtain complete blood count to assess severity of anemia. 5, 6
• Most cases (80-83%) are functional/anovulatory, but organic causes must be excluded. 4, 5

Common Pitfalls to Avoid

• Never prescribe progestins for extended periods beyond 6 months without reassessment due to meningioma risk. 1
• Do not use COCs in very young adolescents (<14 years or within 2 years of menarche) unless clearly indicated, due to bone density concerns. 1
• Do not assume all pubertal menorrhagia is benign anovulation—approximately 20% have underlying pathology including bleeding disorders or endocrine abnormalities. 4, 5
• Curettage is never required in pubertal menorrhagia; medical and hormonal treatment is effective in all cases. 4

Special Considerations

• Severe forms arising during the initial three menstrual cycles are functional in most cases but require treatment lasting several years with high risk of recurrence. 4
• Known hemostatic disorders should have hormone treatment initiated before or at menarche to prevent severe hemorrhage. 4
• NSAIDs (mefenamic acid, naproxen) reduce blood loss by 20-40% but are less effective than COCs or tranexamic acid. 3, 2