What is the appropriate management for a 16-year-old female patient presenting with prolonged menstruation (menorrhagia) of approximately 15 days, dysuria (painful urination), and passing blood clots?

Immediate Management of Prolonged Menstruation with Dysuria in an Adolescent

This 16-year-old requires urgent evaluation for urinary tract infection and pregnancy testing, followed by treatment with NSAIDs for 5-7 days if no contraindications exist, while simultaneously investigating for underlying bleeding disorders given her age and symptom severity. 1, 2

Critical Initial Assessment

Rule out pregnancy immediately with a beta-hCG test in all reproductive-age women presenting with abnormal bleeding, as this is the first priority before any treatment. 1, 2

Evaluate for urinary tract infection given the dysuria (painful urination). The presence of white cells and micro-organisms in the urine clearly indicates the possibility of a urinary tract infection, which requires specific treatment. 3 The dysuria may be related to menstrual blood contamination, but active UTI must be excluded.

Assess hemodynamic stability including orthostatic blood pressure and pulse measurements, as 15 days of bleeding with clots suggests significant blood loss. 4

Check for anemia with complete blood count and serum ferritin, as prolonged bleeding commonly causes iron deficiency. 1, 5, 4

Essential Diagnostic Considerations

Screen for bleeding disorders, as up to 20% of adolescents with heavy menstrual bleeding have an underlying inherited bleeding disorder, most commonly von Willebrand disease. 1, 5, 4 The presence of large blood clots (≥1 inch diameter) and prolonged bleeding for 15 days are highly suggestive of a coagulopathy. 6

Evaluate for structural pathology including fibroids, polyps, or endometrial pathology through pelvic examination (if appropriate for age and sexual activity) and consider vaginal sonography if clinically indicated. 1, 2

Assess for ovulatory dysfunction, which is the most common cause of heavy menstrual bleeding in adolescents. 5, 4

First-Line Medical Treatment

NSAIDs are the recommended first-line treatment for heavy menstrual bleeding, prescribed for 5-7 days during menstruation only. 1, 2, 7 Specific options include:

• Mefenamic acid (most studied in adolescents) 2, 7
• Naproxen 440-550 mg every 12 hours 7
• Ibuprofen 600-800 mg every 6-8 hours, taken with food 7

NSAIDs reduce menstrual blood loss by 20-60% and work by decreasing prostaglandin production in the endometrium. 8, 9

Critical contraindication: NSAIDs must be avoided if there is any cardiovascular disease, as they increase risk of myocardial infarction and thrombosis. 2, 10

Avoid aspirin, as it does not reduce bleeding and may actually increase blood loss in women with lower baseline menstrual blood loss. 1, 2

Alternative Treatment Options

If NSAIDs fail or are contraindicated, tranexamic acid is highly effective, reducing menstrual blood loss by 34-59% over 2-3 cycles. 1, 8, 9 However, tranexamic acid is absolutely contraindicated in women with active thromboembolic disease, history of thrombosis, or cardiovascular disease. 2, 10

For ongoing management after acute bleeding resolves, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective medical treatment, reducing menstrual blood loss by 71-95%. 1, 2, 5 This is safe and effective in adolescents, including those with bleeding disorders. 5

Combined hormonal contraceptives can be used as second-line therapy if NSAIDs fail after 2-3 menstrual cycles, with the added benefits of decreased menstrual blood loss. 7, 4

Important Clinical Pitfalls

Do not assume this is "normal adolescent irregular bleeding" given the 15-day duration and presence of clots. This warrants thorough investigation for bleeding disorders. 5, 4

Do not delay hematology referral if there is flooding (changing pad/tampon more frequently than hourly), clots ≥1 inch diameter, or family history of bleeding disorders. 6, 4

Address the dysuria separately - if UTI is confirmed, treat with appropriate antibiotics. Do not attribute all symptoms to menstruation alone. 3

Counsel about expected bleeding patterns with any treatment initiated, as enhanced counseling improves treatment adherence and reduces discontinuation. 1, 2

When to Escalate Care

Immediate referral to emergency department if hemodynamically unstable or bleeding saturates a large pad or tampon hourly for at least 4 hours. 3, 4

Hematology referral indicated if bleeding disorder suspected based on history, family history, or lack of response to first-line therapy. 5, 4

Gynecology referral warranted if symptoms persist beyond 3 months despite appropriate medical therapy. 7