What is the appropriate evaluation and management for a healthy 15‑year‑old adolescent presenting with menorrhagia?

Management of Menorrhagia in a 15-Year-Old Adolescent

For a healthy 15-year-old with menorrhagia, begin with screening for bleeding disorders and anemia, then initiate first-line treatment with combined oral contraceptives or tranexamic acid while avoiding the levonorgestrel-releasing intrauterine system unless other options fail. 1, 2

Mandatory Initial Evaluation

Screen for Bleeding Disorders

• Obtain a complete blood count, coagulation studies, and von Willebrand factor testing in all adolescents presenting with menorrhagia, as approximately 20% will have an underlying coagulation disorder 3
• This percentage increases to 33% in those requiring transfusion and 50% in those presenting at menarche 3
• Work with a hematologist if bleeding disorder is suspected 2

Assess for Anemia

• Measure hemoglobin/hematocrit and serum ferritin, as menorrhagia is the most common cause of iron deficiency in reproductive-age women, affecting 20-25% 1
• Check orthostatic blood pressure and pulse if acute heavy bleeding is present 2

Evaluate for Endocrine Disorders

• Obtain thyroid-stimulating hormone (TSH) to exclude thyroid dysfunction 4
• Consider follicle-stimulating hormone (FSH) and prolactin if anovulation is suspected 4
• Pregnancy test is mandatory to rule out incomplete abortion 4

Physical Examination Specifics

• Assess hemodynamic stability with orthostatic vital signs 2
• Perform pelvic examination only if clinically indicated; it is not mandatory before initiating treatment in adolescents 5
• Pap smear is not required in this age group 5

First-Line Medical Treatment Algorithm

For Acute Heavy Bleeding (Hemoglobin <10 g/dL or Hemodynamically Unstable)

• Initiate high-dose combined oral contraceptives: Give one pill three times daily until bleeding stops (typically 24-48 hours), then taper to once daily 6
• Add tranexamic acid 1.5-2g three times daily during menstruation for additional hemostatic effect, reducing blood loss by 34-59% 1, 2
• Transfuse if hemoglobin <7 g/dL or patient is symptomatic 6
• If no response within 48 hours, re-evaluate for coagulopathy 6

For Non-Acute Menorrhagia (Hemoglobin ≥10 g/dL, Stable)

Option 1: Combined Oral Contraceptives (Preferred for Adolescents)

• Regularize cycles and significantly reduce bleeding compared to NSAIDs or oral progestins 1, 5
• Screen for contraindications: history of thromboembolism, stroke, cardiovascular disease, migraine with aura, or smoking (though rare in this age group) 5
• Measure blood pressure before prescribing 5

Option 2: Tranexamic Acid (If Hormones Contraindicated or Refused)

• Dose: 1.5-2g three times daily during menstruation only 1
• Particularly effective in bleeding disorders or coagulopathies 1
• Non-hormonal option reduces blood loss by 34-59% over 2-3 cycles 1

Option 3: NSAIDs (Least Effective, Use as Adjunct)

• Mefenamic acid 500mg three times daily for 5-7 days during bleeding 1
• Reduces blood loss by only 20-35%, significantly less effective than other options 1
• Consider only for mild cases or as adjunct therapy 1

Avoid in Adolescents Unless Other Options Fail

• Levonorgestrel-releasing intrauterine system (LNG-IUS): While most effective overall (96% reduction in blood loss), reserve for adolescents who fail other treatments, as insertion may be challenging and acceptance lower in this age group 1, 5
• Depot medroxyprogesterone acetate (DMPA): Avoid due to irregular bleeding and 11-13 week irreversibility 1
• Oral progestins: Do not use for more than 6 months due to meningioma risk 1, 5

Anemia Management

• Prescribe ferrous sulfate 200mg three times daily to correct anemia and replenish iron stores 1
• Add ascorbic acid to improve iron absorption if response is insufficient 1
• Continue treatment for three months after hemoglobin normalizes to replenish stores 1
• Monitor hemoglobin and mean corpuscular volume (MCV) every 3 months for 1 year, then annually 1

Follow-Up Protocol

• Re-evaluate at 3-6 months after initiating treatment to assess efficacy 1, 5
• If bleeding persists despite medical management, consider pelvic ultrasound to exclude structural abnormalities (fibroids, polyps), though these are uncommon in adolescents 7
• Reserve surgical interventions (endometrial ablation, hysterectomy) for those who fail all medical therapies, which is extremely rare in this age group 2, 7

Critical Pitfalls to Avoid

• Do not assume anovulation is the only cause: 20% of adolescents with menorrhagia have bleeding disorders, and this increases to 50% at menarche 3
• Do not use cyclic progestins alone: They do not significantly reduce menstrual bleeding in ovulating women 7
• Do not continue oral progestins beyond 6 months: Risk of meningiomas 1, 5
• Do not delay hematology referral: If no response to hormonal therapy within 48 hours in acute bleeding, re-evaluate for coagulopathy immediately 6
• Do not perform unnecessary invasive procedures: Pelvic exam and Pap smear are not mandatory before starting treatment in adolescents 5