What is the appropriate workup and treatment for a 15-year-old female patient presenting with menorrhagia?

Workup for Menorrhagia in a 15-Year-Old

Screen immediately for iron deficiency anemia and bleeding disorders, particularly von Willebrand disease and platelet function disorders, as these are the most critical initial steps in evaluating an adolescent with menorrhagia. 1

Initial Laboratory Evaluation

Essential First-Line Tests

• Complete blood count (CBC) to assess for anemia, as menorrhagia affects 20-25% of adolescent females and commonly causes iron deficiency 1
• Thyroid stimulating hormone (TSH) to evaluate thyroid dysfunction as a potential cause 2
• Pregnancy test to exclude pregnancy-related bleeding 2

Bleeding Disorder Screening

• von Willebrand factor antigen (VWF:Ag) and Factor VIII activity (FVIII:C) should be obtained during menstrual bleeding to capture the lowest levels, as von Willebrand disease is the most common inherited bleeding disorder in women with prevalence of menorrhagia ranging from 32-100% 3
• Platelet aggregometry must be performed if initial screening tests are normal but clinical suspicion remains high, as platelet secretion defects may be underrecognized causes of adolescent menorrhagia 4
• The prevalence of menorrhagia in bleeding disorders ranges from 5-98% in platelet dysfunction and 35-70% in rare factor deficiencies 3

Clinical Assessment

History Components

• Menstrual pattern details: duration (>7 days is abnormal), frequency, and subjective assessment of blood loss 5, 2
• Pictorial blood loss assessment chart (PBAC): A score >100 has 80% sensitivity and 95% sensitivity when combined with detailed history for detecting true menorrhagia 6, 3
• Personal bleeding history: easy bruising, epistaxis, gingival bleeding, prolonged bleeding from minor cuts 3
• Family history of bleeding disorders or menorrhagia 3
• Medication history, particularly psychotropic medications that cross the blood-brain barrier 2

Physical Examination

• Assess for signs of anemia (pallor, tachycardia) 1
• Evaluate for signs of endocrine disorders (thyroid enlargement, hirsutism suggesting polycystic ovary syndrome) 2
• Pelvic examination is typically not required in adolescents unless there is concern for structural abnormalities or sexual activity 1

Imaging Considerations

Pelvic ultrasound is generally not indicated in adolescents unless there is suspicion for structural pathology (e.g., palpable mass, failure of medical management, or atypical presentation), as anatomic causes are rare in this age group 6

Common Pitfalls to Avoid

• Do not rely on patient history alone to assess blood loss severity, as it is unreliable; use objective measures like PBAC 6
• Do not stop at normal initial coagulation screening (PT, PTT, platelet count) if clinical suspicion is high—proceed to specific von Willebrand testing and platelet aggregometry 4
• Obtain von Willebrand testing during menstruation, not between cycles, as levels fluctuate and may be falsely normal when not bleeding 3
• Do not assume anovulatory bleeding is the sole cause without excluding bleeding disorders, as up to 20% of adolescents with menorrhagia have an underlying coagulopathy 3

Initial Management While Awaiting Results

• Start iron supplementation immediately with ferrous sulfate 200mg three times daily if anemia is present 1
• Consider tranexamic acid 1.5-2g three times daily during menstruation as first-line therapy, which reduces menstrual blood loss by 34-59% over 2-3 cycles 1
• NSAIDs (mefenamic acid 500mg or ibuprofen) for 5-7 days during bleeding episodes can reduce blood loss by 20-35% 1
• Combined oral contraceptives are effective for cycle regulation and bleeding reduction in adolescents 1

Follow-Up Monitoring

• Reassess at 3-6 months after initiating treatment to evaluate efficacy 1
• Monitor hemoglobin and mean corpuscular volume (MCV) every 3 months for 1 year, then annually 1
• Continue iron supplementation for 3 months after anemia correction to replenish iron stores 1