What is the best approach to manage heavy menstrual bleeding in a 14-year-old girl with cerebral palsy (CP), spasticity, and a history of preterm birth at 25 weeks gestation, who experiences monthly bleeding lasting 8 days with clot passage and requires frequent pad changes?

From the Guidelines

For this 14-year-old girl with cerebral palsy experiencing heavy menstrual bleeding, I recommend starting a levonorgestrel intrauterine device (LNG-IUD) as first-line therapy, considering her history of migraines with aura, which makes estrogen-containing methods contraindicated due to increased stroke risk 1. Given her mobility limitations and contractures, the LNG-IUD would provide a convenient and effective method for managing her heavy menstrual periods, with the added benefit of up to 5 years of protection. The LNG-IUD works by thinning the endometrial lining, thereby reducing or eliminating menstrual flow, and has been shown to be a safe and effective option for adolescents with heavy menstrual bleeding, as outlined in the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1. If insertion of the LNG-IUD is not feasible due to her contractures and limited mobility, depot medroxyprogesterone acetate (DMPA) injections every 12 weeks could be considered as an alternative, as it often leads to amenorrhea after several injections and does not contain estrogen, making it a safer option for her given her history of migraines with aura. It is essential to weigh the benefits and risks of each option and consider her individual needs and preferences when making a decision, as emphasized in the management of bleeding irregularities while using contraception, which includes exploring patient goals and providing reassurance and advice on treatment options 1. Key considerations in her management include:

• The need for a convenient and effective method for managing heavy menstrual periods
• The importance of avoiding estrogen-containing methods due to her history of migraines with aura
• The potential benefits and risks of each option, including the LNG-IUD and DMPA injections
• The need for individualized care and consideration of her unique needs and preferences, as outlined in the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.

From the FDA Drug Label

5 WARNINGS AND PRECAUTIONS

5.1 Thromboembolic Risk Tranexamic acid is contraindicated in patients with active intravascular clotting. Tranexamic acid is an antifibrinolytic and may increase the risk of thromboembolic events. Venous and arterial thrombosis or thromboembolism has been reported in patients treated with Tranexamic acid Avoid concomitant use of Tranexamic acid and medical products that are pro-thrombotic, as the risk of thrombosis may be increased.

The patient has heavy menstrual periods with passage of clots, and the parents are seeking help in managing them.

• The use of tranexamic acid may increase the risk of thromboembolic events.
• There is no information in the provided drug label that directly supports the use of tranexamic acid in a 14-year-old girl with heavy menstrual periods, cerebral palsy, and other comorbidities.
• Given the potential risks, a conservative clinical decision would be to avoid the use of tranexamic acid in this patient until more information is available, or to consider alternative treatments for managing heavy menstrual periods. 2

From the Research

Management of Heavy Menstrual Periods

The patient, a 14-year-old girl with cerebral palsy and limited mobility, is experiencing heavy menstrual periods that last 8 days with passage of clots, requiring frequent pad changes. Her parents are seeking help in managing her condition.

• Treatment Options: According to the studies, several treatment options are available for heavy menstrual bleeding (HMB), including medical and surgical interventions 3, 4, 5, 6, 7.
• Medical Interventions: Medical interventions such as non-steroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics (tranexamic acid), combined oral contraceptives (COC), and the levonorgestrel-releasing intrauterine system (LNG-IUS) have been shown to be effective in reducing menstrual blood loss (MBL) 3, 4, 5, 6, 7.
• LNG-IUS: The LNG-IUS is a highly effective treatment option for HMB, reducing MBL to a greater extent than other medical therapies, including COC and oral progestogens 3, 5.
• Combined Oral Contraceptives: COC have also been shown to be effective in reducing HMB, with moderate-quality evidence suggesting that they reduce MBL and improve treatment response 4.
• Surgical Interventions: Surgical interventions such as hysterectomy and endometrial ablation may also be considered for women with HMB who have failed medical therapy or have underlying uterine pathology 3, 5.
• Quality of Life: Treatment of HMB can improve quality of life, with the LNG-IUS and COC showing positive effects on bleeding-related quality of life 5, 7.
• Individualized Treatment: The best treatment option for the patient will depend on her individual circumstances, including her age, desire for future pregnancy, and personal preferences 3, 6.