How to manage a 14-year-old female patient with menometorrhagia (heavy menstrual bleeding), severe anemia (hemoglobin level of 8.8 g/dL), symptoms of pallor, headache, and dizziness, weighing 43 kilograms, with either fresh whole blood (FWB) or packed red blood cells (RBCs)?

Management of Severe Anemia in Adolescent with Menometrorrhagia

Transfuse this patient with packed red blood cells (PRBCs), not fresh whole blood, targeting a hemoglobin of 7-8 g/dL initially, given her symptomatic severe anemia (Hgb 8.8 g/dL) with pallor, headache, and dizziness. 1

Immediate Transfusion Decision

This patient requires blood transfusion because she has severe anemia (Hgb <10 g/dL) with clear symptoms of hemodynamic compromise (pallor, headache, dizziness), which indicate inadequate tissue oxygenation. 1

Why Packed RBCs, Not Fresh Whole Blood:

• Packed RBCs are the standard of care for symptomatic anemia in stable patients, providing concentrated red cells without unnecessary plasma volume that could cause fluid overload in a 43 kg adolescent 1
• Fresh whole blood is reserved for massive hemorrhage requiring coagulation factors, which is not the case here 1
• Target hemoglobin should be 7-8 g/dL initially using single-unit transfusions, reassessing after each unit, as liberal transfusion strategies (targeting Hgb >10 g/dL) do not improve outcomes and may increase complications 2

Transfusion Protocol:

• Calculate volume: For a 43 kg patient, each unit of PRBCs (approximately 10-15 mL/kg) should raise hemoglobin by approximately 1-1.5 g/dL 1
• Transfuse 1-2 units initially, then reassess symptoms and hemoglobin 2
• Monitor for transfusion reactions and fluid overload given her small body habitus 1

Concurrent Management of Menometrorrhagia

While addressing the acute anemia, immediately initiate treatment to stop the bleeding:

First-Line Medical Therapy:

• Tranexamic acid (antifibrinolytic): Most effective acute treatment, reduces menstrual blood loss by 40-60% 3
• NSAIDs (ibuprofen or naproxen): Reduce bleeding by 20-50% and provide pain relief 3
• Combined oral contraceptives or high-dose progestins can be used to stop acute bleeding 4, 3

Hormonal IUD for Long-Term Management:

• Levonorgestrel intrauterine system (IUS) is highly effective for long-term control, comparable to surgical interventions, and should be considered once acute bleeding is controlled 4, 3

Essential Diagnostic Workup

Before or concurrent with transfusion, obtain:

• Complete blood count with reticulocyte count to assess bone marrow response 5
• Iron studies (ferritin, transferrin saturation, serum iron): Ferritin <30 μg/L confirms iron deficiency 5
• Coagulation studies including von Willebrand factor panel, as bleeding disorders (especially von Willebrand disease) are common in adolescents with menometrorrhagia 4, 6
• Pelvic ultrasound to exclude structural abnormalities (polyps, fibroids, though less common in adolescents) 4, 6, 3
• Pregnancy test (mandatory in any reproductive-age female with abnormal bleeding) 6

Iron Repletion Strategy

After transfusion and bleeding control, aggressive iron replacement is essential:

• Oral iron supplementation (ferrous sulfate 325 mg 2-3 times daily) is first-line for non-acute management 5
• Intravenous iron should be considered if oral iron is not tolerated or if rapid repletion is needed, especially given the severity of her iron deficiency 5, 7
• Continue iron therapy for 3-6 months after hemoglobin normalizes to replete iron stores 5

Critical Monitoring Parameters

Close follow-up is mandatory:

• Recheck hemoglobin 24-48 hours post-transfusion to ensure adequate response 1
• Monitor for continued bleeding and effectiveness of medical therapy 3
• Reassess hemoglobin weekly until stable, then monthly during iron repletion 5
• If bleeding persists despite medical therapy, consider gynecology referral for hysteroscopy or endometrial sampling, though malignancy is rare in this age group 4, 6, 3

Common Pitfalls to Avoid

• Do not over-transfuse: Targeting Hgb >10 g/dL increases complications without improving outcomes 2
• Do not use fresh whole blood in stable patients with chronic anemia 1
• Do not delay iron supplementation: Even after transfusion, iron stores remain depleted and require months of repletion 5, 7
• Do not miss underlying bleeding disorders: Up to 20% of adolescents with menometrorrhagia have coagulation abnormalities 4
• Do not forget contraception counseling: If using hormonal therapy, discuss compliance and side effects 3