Management of Persistent Vaginal Bleeding in a 14-Year-Old Girl
For a 14-year-old with one month of vaginal bleeding, the priority is to rule out pregnancy, structural abnormalities, bleeding disorders, and infection, then initiate treatment with NSAIDs (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) for 5-7 days during bleeding episodes, with combined oral contraceptives (30-35 μg ethinyl estradiol) as second-line therapy if NSAIDs fail after 2-3 cycles. 1, 2
Initial Diagnostic Evaluation
Before initiating treatment, specific conditions must be excluded:
- Rule out pregnancy - This is mandatory even in adolescents, as pregnancy-related bleeding requires completely different management 3
- Assess for bleeding disorders - Factor X deficiency and Von Willebrand disease can present with heavy menstrual bleeding in adolescent girls; these require clotting factor replacement rather than hormonal therapy 4
- Exclude structural pathology - Fibroids, polyps, or other uterine abnormalities must be identified, as they require specific treatment 1
- Screen for sexually transmitted infections - STIs can cause abnormal bleeding and must be treated appropriately 1
First-Line Pharmacological Treatment
NSAIDs are the initial treatment of choice:
- Ibuprofen 600-800 mg every 6-8 hours OR naproxen 440-550 mg every 12 hours, taken with food 1
- Duration: 5-7 days during bleeding episodes only 1, 2
- NSAIDs work by reducing prostaglandin production and decreasing menstrual blood flow 1
- Approximately 18% of adolescents will not respond to NSAIDs and require escalation 2
Second-Line Hormonal Treatment
If NSAIDs fail after 2-3 menstrual cycles, combined oral contraceptives are recommended:
- Monophasic COCs containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate 1
- Monophasic formulations are preferred for simplicity in adolescents 1
- Extended or continuous cycles (minimizing hormone-free intervals) are particularly appropriate for persistent bleeding, as they optimize ovarian suppression 1
- COCs provide additional benefits including decreased menstrual blood loss, improvement in acne, and are completely reversible with no negative effect on long-term fertility 1
Alternative Hormonal Options
If COCs are contraindicated or ineffective:
- Short-term hormonal treatment with low-dose COCs or estrogen for 10-20 days can be used specifically during bleeding episodes 4, 2
- Depot medroxyprogesterone acetate (DMPA) can be considered as second-line treatment, though amenorrhea typically occurs only after ≥1 year of continuous use 2
- Levonorgestrel intrauterine system is an option for heavy menstrual bleeding, though less commonly used as first-line in adolescents 4
Adjunctive Non-Pharmacological Measures
These can be used alongside pharmacological treatment:
- Heat therapy applied to abdomen or back may reduce cramping pain 1
- Acupressure on Large Intestine-4 (LI4) point on dorsum of hand and Spleen-6 (SP6) point approximately 4 fingers above medial malleolus 1
- Peppermint essential oil has shown benefit in decreasing dysmenorrhea symptoms 1
Important Clinical Pitfalls
Do not assume this is simple dysfunctional bleeding without proper evaluation. While irregular bleeding is common in adolescents due to anovulatory cycles, one month of persistent bleeding warrants investigation. 5, 6
Bleeding disorders are often missed in adolescents. Factor X deficiency specifically presents with heavy menstrual bleeding in girls and requires clotting factor replacement (25-30.5 IU/kg pdFX), not hormonal therapy. 4
If bleeding persists despite treatment or is unacceptable to the patient, counsel on alternative contraceptive methods and consider referral for further evaluation. 4, 2 Persistent or recurrent abnormal bleeding requires adequate diagnostic measures to rule out pathology. 3
Ensure proper adherence counseling - Adolescents may benefit from strategies like cell phone alarms to promote daily adherence if COCs are prescribed. 4 Seven consecutive hormone pills are needed to prevent ovulation. 4