What is the diagnosis and treatment for a 16-year-old female with menorrhagia (prolonged menstruation), dysuria (pain in the pubic area when urinating), and blood clotting?

Diagnosis and Management of Prolonged Menstruation with Dysuria in a 16-Year-Old

This patient requires immediate evaluation for both menorrhagia (prolonged menstruation beyond 7 days) and a concurrent urinary tract infection, with urgent screening for iron deficiency anemia and initiation of tranexamic acid therapy while addressing the urinary symptoms. 1

Immediate Diagnostic Priorities

Menorrhagia Assessment

• Screen immediately for iron deficiency anemia (hemoglobin and ferritin), as 20-25% of adolescents with menorrhagia develop anemia 1
• Document bleeding pattern specifics: presence of clots ≥1 inch diameter, "flooding" (changing pad/tampon more than hourly), and duration of symptoms 2
• Obtain complete blood count with platelets to assess for underlying bleeding disorders, particularly given the 16-day duration and blood clotting 1, 2

Urinary Symptoms Evaluation

• Obtain urine culture before starting antibiotics to confirm urinary tract infection as the cause of dysuria 3
• Perform urinalysis to detect hematuria, pyuria, or bacteriuria 3
• The combination of pelvic pain and dysuria suggests possible concurrent UTI, which must be treated separately from menorrhagia 3

First-Line Treatment Approach

For Menorrhagia

Initiate tranexamic acid 1.5-2g three times daily during menstruation, which reduces menstrual blood loss by 34-59% over 2-3 cycles 1. This is the preferred first-line therapy for adolescent menorrhagia and can be started immediately while completing the diagnostic workup.

Alternative first-line options if tranexamic acid is unavailable:

• NSAIDs: Mefenamic acid 500mg three times daily or ibuprofen for 5-7 days during bleeding episodes 1
• These agents reduce menstrual blood loss by 20-60% 4

For Dysuria/UTI

• Treat confirmed UTI with appropriate antibiotics based on culture results 3
• Ensure adequate hydration and symptom monitoring

Anemia Management

If anemia is confirmed:

• Start ferrous sulfate 200mg three times daily 1
• Continue treatment for three months after correction of anemia to replenish iron stores 1
• Monitor hemoglobin and MCV every 3 months for 1 year, then annually 1

Secondary Treatment Considerations

If tranexamic acid or NSAIDs fail after 2-3 cycles:

• Combined oral contraceptives are effective for regularizing cycles and reducing bleeding in adolescents 1
• Provide thorough counseling about expected bleeding patterns to prevent non-adherence 1
• Oral progestins (norethindrone) may be considered but should not be used for more than 6 months due to meningioma risk 1

Critical Pitfalls to Avoid

Do not assume anticoagulant therapy is the cause without proper evaluation, as this patient's age makes this unlikely 3, 2

Do not delay anemia screening - waiting can lead to severe iron deficiency requiring more aggressive intervention 1

Do not attribute all symptoms to menstruation - the dysuria requires separate evaluation and treatment for possible UTI 3

Do not use cyclic progestins alone in adolescents who ovulate, as they do not significantly reduce menstrual bleeding 4

When to Refer

Consider hematology referral if:

• Menorrhagia persists despite first-line therapy 2
• Family history of bleeding disorders is present 2
• Severe anemia or thrombocytopenia is detected 1

The combination of prolonged menstruation (16 days) with blood clots and concurrent urinary symptoms requires simultaneous management of both conditions, with menorrhagia treatment taking priority for long-term morbidity prevention while addressing the acute urinary infection 1, 2.