What is the appropriate work‑up and first‑line management for a 16‑year‑old adolescent presenting with menorrhagia (heavy menstrual bleeding lasting >7 days or requiring a pad/tampon change every 1–2 hours)?

Management of Menorrhagia in a 16-Year-Old Adolescent

Initial Evaluation

Screen for bleeding disorders immediately in any adolescent presenting with heavy menstrual bleeding, as von Willebrand disease affects 13-32% of adolescents with menorrhagia and is the most common inherited bleeding disorder in this population. 1, 2

Essential History Components

• Duration of bleeding (>7 days is abnormal) and frequency of pad/tampon changes (every 1-2 hours indicates heavy flow) 1
• Presence of clots larger than a quarter, flooding through protection, or bleeding that interferes with daily activities 1
• Personal bleeding history: easy bruising, prolonged bleeding from minor cuts, nosebleeds lasting >10 minutes, bleeding after dental procedures or surgery 1, 2
• Family history of bleeding disorders, particularly in female relatives with heavy periods, postpartum hemorrhage, or surgical bleeding complications 1
• Medication use, particularly anticoagulants or NSAIDs 1

Physical Examination Priorities

• Assess hemodynamic stability with orthostatic vital signs (blood pressure and pulse both lying and standing) to identify significant blood loss requiring urgent intervention 1
• Look for signs of anemia: pallor, tachycardia, fatigue 1
• Examine for petechiae, ecchymoses, or other bleeding stigmata suggesting platelet dysfunction or coagulopathy 1

Laboratory Work-Up

Order a complete blood count with platelets, ferritin, TSH, and bleeding disorder screening (PT, aPTT, fibrinogen, von Willebrand factor antigen, von Willebrand factor activity, and factor VIII) at the time of menstrual bleeding to capture the lowest levels 3, 1, 2

• CBC identifies anemia (hemoglobin <12 g/dL) and thrombocytopenia 1
• Ferritin <15 ng/mL indicates iron deficiency from chronic blood loss 1
• TSH screens for hypothyroidism causing anovulatory bleeding 1
• Bleeding disorder testing should ideally be performed during menses when von Willebrand factor levels are lowest 3
• Coordinate with a hematologist if bleeding disorder is suspected based on history or initial screening results 1

First-Line Medical Management

Combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are the first-line treatment for adolescent menorrhagia, reducing menstrual blood loss by inducing regular shedding of a thinner endometrium 4, 5

Hormonal Treatment Options

Monophasic COCs with 30-35 μg ethinyl estradiol taken continuously for 21 consecutive days before any hormone-free interval provide effective menstrual regulation and contraception 4

• Extended regimens (taking active pills continuously for 3-4 months) are particularly useful for treating anemia and severe bleeding 4
• If breakthrough bleeding occurs with extended regimens, allow a 3-4 day hormone-free interval, but not during the first 21 days of use and not more than once per month 4
• COCs provide additional benefits including improvement in acne and reduced risk of endometrial and ovarian cancers 4
• No backup contraception is needed if COCs are started within 5 days of menstrual bleeding onset; use backup for 7 days if started later 4

The 52-mg levonorgestrel intrauterine device is superior to other hormonal methods, reducing menstrual blood loss by 71-95%, and is safe and effective in adolescents with bleeding disorders 2, 4

• Insert within the first 7 days of the menstrual cycle to avoid need for backup contraception 4
• Backup contraception for 7 days is needed only if inserted >7 days after menses starts 4
• Irregular spotting is common during the first 3-6 months but typically resolves 4

Non-Hormonal Hemostatic Agents

Tranexamic acid is an effective antifibrinolytic agent that can be used alone or in combination with hormonal therapy, particularly valuable in adolescents with bleeding disorders 3, 1

• Available in oral and intravenous formulations for acute bleeding episodes 1
• Can be combined with hormonal contraceptives for enhanced bleeding control 1
• Aminocaproic acid is an alternative antifibrinolytic option 1

Management of Acute Heavy Bleeding

For hemodynamically unstable adolescents with acute heavy bleeding, initiate high-dose hormonal therapy: monophasic COC (30-35 μg ethinyl estradiol) three times daily until bleeding stops (usually 1-3 days), then taper to twice daily for 3 days, then once daily for at least 21 consecutive days before any hormone-free interval 4

• Intravenous conjugated estrogen (25 mg every 4-6 hours for up to 24 hours) may be used for severe bleeding unresponsive to oral therapy 1
• Tranexamic acid (oral or IV) should be added to hormonal therapy for acute bleeding 1
• Surgery should be reserved only for those who do not respond to medical therapy or are clinically unstable despite initial measures 1

Special Considerations for Bleeding Disorders

If von Willebrand disease or other bleeding disorder is confirmed, coordinate ongoing care with a hematologist and consider desmopressin (DDAVP) for type 1 VWD or factor replacement products for more severe cases 3, 1

• Desmopressin is a non-transfusional agent effective for type 1 von Willebrand disease 3
• Purified factor VIII/VWF concentrates may be needed for severe bleeding or surgical procedures 3
• Counsel all adolescents with bleeding disorders about avoiding aspirin and NSAIDs (except when used therapeutically for menorrhagia), and discuss implications for future surgery and pregnancy 1

Monitoring and Follow-Up

• Blood pressure monitoring at follow-up visits for patients on COCs 4
• Assess hemoglobin and ferritin after 3 months of treatment to ensure anemia correction 1
• No routine follow-up visit is required for IUD placement; patients should return only for concerning symptoms 4
• Emphasize consistent condom use for STI protection regardless of contraceptive method chosen 4

Common Pitfalls to Avoid

• Do not delay bleeding disorder screening until after hormonal therapy fails—test at initial presentation, ideally during menses 3, 1
• Do not use copper IUDs in adolescents with heavy bleeding, as they worsen menorrhagia 4
• Do not assume anovulation is the cause without ruling out bleeding disorders, as 13-32% of adolescents with HMB have von Willebrand disease 1, 2
• Before treating breakthrough bleeding on hormonal therapy, rule out pregnancy, STIs, medication interactions, and new uterine pathology 4