Initial Treatment for Acute Abnormal Uterine Bleeding in a 15-Year-Old
Combined hormonal contraceptives (CHCs) are the first-line treatment for mild to moderate abnormal uterine bleeding in adolescents with anovulation, which is the most common cause in this age group. 1
Immediate Assessment Priorities
Before initiating treatment, perform these essential evaluations:
- Assess hemodynamic stability first - urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 2
- Pregnancy test (β-hCG) is mandatory in all adolescents with AUB to rule out pregnancy-related bleeding 1
- Check TSH and prolactin levels to exclude thyroid dysfunction and hyperprolactinemia as underlying causes 1
- Complete blood count to assess for anemia and guide treatment intensity 3
- Evaluate for hyperandrogenism (acne, hirsutism) that may suggest polycystic ovary syndrome 1
Treatment Algorithm Based on Bleeding Severity
For Mild to Moderate Bleeding
Combined hormonal contraceptives are the preferred first-line option for adolescents with anovulatory bleeding 1. This recommendation is based on the understanding that anovulation from hypothalamic-pituitary-ovarian axis immaturity is the most common cause of dysfunctional uterine bleeding in the first 2-3 post-menarchal years 4.
Alternative hormonal options include:
- Progestin-only pills (oral) 1
- Injectable progestins 1
- Oral progestins for 21 days per month for cyclic heavy bleeding 3
For Acute Heavy Bleeding
If bleeding is severe enough to cause hemodynamic instability, more aggressive hormonal regimens are indicated:
- Multidose combined oral contraceptive regimen (high-dose estrogen-progestin) 5
- Multidose progestin-only regimen 5
- Tranexamic acid (antifibrinolytic agent) can be added to hormonal therapy 4, 5
NSAIDs may be combined with hormonal methods to further reduce bleeding volume 3, 4, though this is typically an adjunctive rather than primary therapy.
Imaging Considerations
Transabdominal ultrasound is the preferred initial imaging modality for adolescent virgins with AUB 1. Transvaginal ultrasound may be appropriate in sexually active adolescents 1. Imaging helps identify structural causes including polyps, adenomyosis, or leiomyomas, though these are rare in this age group 1.
Common Pitfalls to Avoid
- Do not skip pregnancy testing - this is non-negotiable regardless of sexual history reported 1
- Do not assume all adolescent AUB is benign anovulation - screen for coagulopathies, especially if bleeding has been heavy since menarche 4
- Do not use levonorgestrel-releasing IUD as first-line in nulliparous adolescents - while highly effective in adults (71-95% reduction in menstrual blood loss) 3, CHCs remain preferred initial therapy in this age group 1
Follow-Up and Treatment Adjustment
If medical treatment fails, further investigation with advanced imaging or hysteroscopy is indicated 1. However, surgical options such as hysteroscopic removal of polyps are rarely needed in adolescents 1. Treatment should be adjusted based on response and tolerability 1.
The key distinction in adolescent management is recognizing that anovulation from hypothalamic-pituitary-ovarian axis immaturity is the expected physiologic cause 4, making hormonal regulation with CHCs both therapeutic and appropriate for this developmental stage.